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The sacred vs. the secular : evangelical Christian psychologists’ religious values and ethical practice Irvine, Kathleen A. 2003

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THE S A C R E D V S THE S E C U L A R : EVANGELICAL CHRISTIAN P S Y C H O L O G I S T S ' RELIGIOUS V A L U E S AND ETHICAL PRACTICE by K A T H L E E N A. IRVINE B . S c , Mount Saint Vincent University, 1976 M.Ed., Acadia University, 1994 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF T H E REQUIREMENTS FOR THE D E G R E E OF DOCTOR OF PHILOSOPHY in THE F A C U L T Y OF G R A D U A T E STUDIES Department of Educational and Counselling Psychology and Special Education Counselling Psychology Program We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 2003 © Kathleen Anne Irvine, 2003 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of o The University of British Columbia Vancouver, Canada DE-6 (2/88) Abstract Evangelical Christian psychologists sometimes experience tension between their religious and moral values and the values represented by the ethics codes of their professional associations. A qualitative study, using the Critical Incident Technique (CIT), was done to explore the question: "What factors help or hinder evangelical Christian psychologists in dealing with the tensions they experience between their religious moral values and the ethics of professional psychological practice as embodied in professional ethics codes?" Twelve participants identified a variety of tensions and factors that helped and hindered in resolving these tensions. Their responses were categorized into 306 incidents, which were organized into 13 helping categories and 5 hindering categories. Experiencing support, engaging in a process of self-reflection, acquiring knowledge, being open to God, and being clear on beliefs and roles were the primary factors that helped participants deal with these tensions. Table of Contents Abstract ii Table of Contents iii List of Tables vi Acknowledgements vii Chapter 1 - Introduction 1 Assumption 6 Rationale for the Study 7 Approach to the Study 8 Definition of Terms 11 Chapter 2 - Literature Review 13 Ethics and Ethical Decision Making 13 Values in Psychological Practice 18 Resolving Value Conflicts 24 Ethical decision-making 25 Values clarification 26 Cognitive Dissonance Theory 27 Spirituality and Religion in Psychological Practice 28 Religious Coping 34 Christians in Clinical Practice 37 Chapter 3 - Method 45 Design 48 Critical Incident Technique 48 Researcher's Role 51 Establishing the Aim of the Study 53 Participants 54 Procedures 57 Recruitment of Participants 57 Interviews 58 Analysis of Data 61 Analysis of Group B Participants 64 Establishing Validity and Trustworthiness 64 Chapter IV - Results 70 Tensions 70 Being a Psychologist 72 iii Integrating Religious Beliefs and Practice 73 Clients with Conflicting Values 75 Dual Relationships 77 Other Tensions 78 Description of the categories 79 Helping categories 82 Experiencing direct support 83 Following God's teaching/open to God 85 Formulating beliefs and commitments 88 Acquiring knowledge, training, & experience 90 Engaging in a process of self reflection/growth 93 Clarifying goals and roles 95 Promoting client choice and responsibility 97 Using self-disclosure to facilitate client empowerment 99 Managing amount of engagement 100 Engaging in Spiritual disciplines 102 Possessing personal qualities 104 Accepting and seeking out challenges 106 Accepting people 107 Hindering categories 109 My own disruptive reactions 109 Antagonistic beliefs and biases 111 Lack of understanding and support 113 Not knowing 115 Legal concerns 116 Validation Procedures 117 Independent Extraction of the Critical Incidents 118 Expert validation 118 Participants' Cross-checking 120 Independent raters 121 Exhaustiveness 122 Participation rate 122 Theoretical agreement 123 Experiencing support/lack of understanding and Support 123 Following God's teaching/open to God 124 Formulating beliefs & commitments/clarifying Goals & roles 125 Acquiring knowledge & training/not knowing 125 Engaging in a process of self-reflection 125 Promoting client choice 126 Using self-disclosure 126 Managing amount of engagement 127 Engaging in spiritual disciplines 127 Possessing personal qualities 127 Seeking out challenges 127 iv Accepting people 128 My own disruptive reactions 128 Antagonistic beliefs and biases 128 Legal concerns 129 Summary 129 Chapter V - Discussion 130 Christian Worldview 131 Spiritual Coping 134 Support vs. Lack of Support 137 The underlying process 139 Values' conflicts 145 Ethical decision-making 145 Values clarification 149 Cognitive Dissonance 150 Summary 152 Limitations of the Study 153 Implications for Theory and Practice 155 Implications for Counselling Psychology 158 Future Research 161 An Addendum: The Process of Reflexivity 162 References... 168 Appendix A - Letter to Prospective Participants 186 Appendix B - Participant Informed Consent Form 188 Appendix C - Demographic Information 190 Appendix D - Interview Questions 191 Appendix E - E-mail Advertisement 192 Appendix F - Recruitment Letter - Conference Participants 193 Appendix G - Validation Letter and Instructions 195 Appendix H - Letter to Expert Validators 197 Appendix I - Letter to "Group B" Participants 199 Appendix J - Group B Participants 200 v Appendix K - Results from Group B Participants 201 List of Tables Table 1- Demographic Information 56 Table 2 - Helping and Hindering Categories 81 vi Acknowledgements Many people have helped me in the process of completing this research. I really could not have done it without the support of my very patient, loving, and accommodating husband, David. He has sacrificed much to see me through this and I am very grateful. My children, Joanna and Cale, have also been wonderful in their encouragement and ability to tolerate my busy-ness and single-minded focus that, at times, did not leave much room for them. These three people have helped to keep me balanced and reminded me to laugh - at myself and at the many wonderful things we have shared along the way. My supervisor, Beth Haverkamp has been my steady guide throughout my doctoral program. We have had many conversations about this research and I have appreciated greatly her direction - and enthusiasm - at every step. My other committee members have also helped the process to go smoothly - thanks to Mark Davies and Bill Borgen. My classmate and friend, Alan, lived through much of the writing process with me as we laboured together and used one another for a sounding board, feedback, and encouragement to continue. I am also grateful to other people who encouraged me and provided helpful feedback - Laura Lee, Matt, Marvin, Don, Maudine, and Suzanne. Last, but certainly not least, my heartfelt thanks goes to the men and women who gave so freely of their time to participate in this research. I wish I could name each one of you because without you this project would never have been completed. vii Chapter 1 - Introduction This research is about ethics and values in therapeutic practice; in particular, how psychologists resolve tensions they may feel between their religious values and professional standards of ethical practice. Therapy was once thought to be a value-free enterprise but in the past 20 years this premise has been set aside, with the recognition that values permeate all aspects of the therapeutic process (Bergin, 1980; Corey, Corey, & Callanan, 1998). Corey, Corey, and Callanan (1998) suggest that it is neither possible nor desirable for therapists to aim for value neutrality. These authors point out that although it is not the role of counsellors to persuade clients to accept any particular values, counsellors do need to be clear about what their values are and how these may impact clients in the therapy process. Tjeltveit (1999) contends that therapists can significantly impact the values of clients and, in response to this effect, they must consider carefully the appropriateness or inappropriateness of this influence. The recognition that therapy is not value free is a only a starting place; it is important to develop a deeper understanding of the ways in which therapy is value-laden and the impact this can have on ethical practice (Tjeltveit, 1999). Tjeltveit (1999) says that this discussion must begin with a clear understanding of how the term "values" is being used in a given context. The term values can be used in many different ways: values as psychological, values as ethical, values as a means by which the powerful impose their will on the weak, values as choices, values as authentic expressions of an individual's nature, and values as cultural and historical (Tjeltveit, 1999, pp. 84, 85). In this research I will adopt a psychological definition of 1 the term values to mean "what people value, judge to have value, think to be good, or desire" (Tjeltveit, 1999, p. 85) in a manner that clarifies the ethical dimensions of psychotherapy. Therefore, I will be using the term values primarily in the ethical sense, as those values that guide morality and moral decision-making, and help to provide answers to questions about what is "right" and "wrong." The values that pervade therapy processes have become topics of scrutiny in the psychology and counselling literature (Bergin, 1980). This includes the therapist's personal values, the client's values, and the values that therapists consider vital to the change process and healthy functioning. Therapists are encouraged to be aware of the personal values that they bring into the therapy process, and to reflect on these with great care so as to minimize any potential harm to clients (Tjeltveit, 1999). Many therapists hold strong moral values that guide thoughts and feelings about right and wrong behaviour. It is not uncommon for therapists to hold different values than those of their clients. For instance, a client may be facing a pregnancy after being raped but does not want to have an abortion for religious reasons. A "pro-choice" therapist may have difficulty understanding the moral implications of this decision for the client. Prilleltensky (1997) asserts that values, assumptions, and behaviour practices are closely related. We make assumptions about people based on our values. If the therapist in the above example highly values a woman's rights over her own body, he/she may make the assumption that this client has the right to choose an abortion apart from any moral or cultural norms, especially in light of the traumatic context of the pregnancy. These ideas will then likely influence practice. Therapy efforts may be directed at 2 promoting independence of action, apart from "old-fashioned" religious traditions. Therapist convictions and descriptions of mental health are based on values (Bergin, 1991). Jensen and Bergin (1988), reporting on a study of 425 mental health professionals, found a high consensus on the following factors as constituting a mentally healthy lifestyle: ...Being a free agent; having a sense of identity and feelings of worth; being skilled in interpersonal communication, sensitivity, nurturance, and trust; being genuine and honest; having self-control and personal responsibility; being committed in marriage, family, and social relationships; having a capacity to forgive others and oneself; having orienting values and meaningful purposes; having deepened self-awareness and motivation for growth; having adaptive coping strategies for managing stresses and crises; finding fulfilment in work; and practicing good habits of physical health (pp. 394-95). Two other themes emerged, centred on a traditional conception of sexuality and spirituality/religiosity, but there was not such a high consensus. This suggests that there is a subgroup of mental health professionals who hold distinct value perspectives in these realms, however, there was no elaboration of these results. All therapists have a conception of what constitutes mental health, based on values and assumptions regarding human nature that describe attitudes and behaviours that are "good" and "desirable." Jensen and Bergin's (1988) study showed that mental health professionals endeavour to orient their work with clients according to these value-based tenets. 3 The study of ethics is closely related to values as both consider questions of right and wrong. Ethics is the study of those assumptions held by individuals, institutions, organizations, and professions that they believe will assist them in distinguishing between right and wrong and, ultimately, in making sound moral judgments. (Bersoff, 1995, p. xix) Professional ethics codes are grounded in values from which come guidelines for ethical behaviour (Bersoff, 1995). The preamble to the 1992 Ethics Code of A P A states: "This Ethics Code provides a common set of values upon which psychologists build their professional and scientific work" (American Psychological Association, 1992). These codes generally reflect consensus values by members of a profession and, occasionally, a particular member of such an association may find that a personal value is in conflict with the values of a written code (Chapelle, 2000; Smith, McGuire, Abbott, & Blair, 1991). The most recent code of ethics for the American Psychological Association (APA, 2002) demonstrates a value of respect for human differences and nondiscrimination and includes religion as one of the elements of cultural diversity to be considered in providing psychological services. Psychologists are encouraged to be aware of the impact of religion and spirituality in their clients' lives, and to develop some competence in dealing with these issues. In light of this mandate to respect cultural diversity, a therapist's avoidance or invalidation of a client's spiritual or religious issues is a significant source of ethical conflict (Bishop, 1992). For others, the incorporation of religious values (of both client and psychologist) 4 presents significant challenges to ethical practice. Walker, Pitts, Hennig, and Matsuba (1995) found that, for many of the participants in their study, morality was firmly embedded and governed by their religious faith. The concerns pursued in this research involved the occasions when a psychologist's religious, moral values come into conflict with the values represented in ethical codes. Religion is increasingly recognized as a central element in many people's lives (Bibby, 2000) and a major source of values (Bergin, 1980; Walker, Pitts, Hennig, & Matsuba, 1995) for many people. Interest in the integration of spirituality and religion in psychological practice has grown tremendously in the past two decades, counteracting the estrangement that has characterized the relationship between religion and psychology since the establishment of psychology as an empirical science (Mack, 1994). Westgate (1996) observed that early humanists, from the 12 t h to 14 t h centuries, did not find spirituality and reason incompatible; but, the Age of Enlightenment, around the 18th century, glorified reason, making spirituality irrelevant, even irrational. Bergin (1980), in a groundbreaking article, proposed ways of broadening psychology's horizon to include and integrate religion and religious values in theory and practice. My interest in this topic stems from a desire to integrate my own religious values into the therapy process. Christianity is the foundation of my life, and informs my thinking, behaviour, and practice as a counsellor. I would define myself as an evangelical Christian, using Hoge's (1996) description: "They [evangelicals] adhere to quite a literal interpretation of the Bible, and they emphasize conversion and development of a personal relationship with Jesus Christ" (p. 28). As I navigated 5 troubled times in my life, and went to therapists for assistance, I found the counselling incomplete when it did not include a Christian religious emphasis. Several years ago, prior to starting my PhD, I owned a private counselling practice in a small rural community, and although I did not advertise myself as a Christian counsellor, many of my clients came to me because of this religious affiliation. If the client desired, I would include some spiritual interventions in our work together (e.g., prayer, scripture reading). However, I had not, until recently, given much thought to the ethics of this practice, and in particular how my Christian values could impact my clients. My religious teachings appear to embrace some definite injunctions against certain kinds of behaviour, such as extramarital sex, abortion, and homosexual acts. How do therapists, including myself, balance these personal, moral precepts with a professional mandate to respect diversity and ensure client autonomy? This is the question that I ask myself and that this research examined. It is, for me, one small step in the process of integrating my own Christian faith with psychological practice. Assumption The basic assumption underlying this study is that personal assumptions and values underlie the development of psychological theory and the practice of psychology (Bergin, 1980; Jones, 1994). This is consistent with the recognition that there is no such thing as value-free therapy (Corey, Corey, & Callanan, 1998; Tjeltveit, 1999). 6 Rationale for the Study The purpose of this study is to explore the tensions evangelical Christian psychologists feel between strong, religious moral values and the values embraced by the ethics codes of the professional associations to which they belong. There is a growing acknowledgment in the psychological literature that therapist values have a major impact on the therapeutic process (Bergin, 1980, Bergin, 1991; Enns & Hackett, 1990; Epperson & Lewis, 1987; Lewis, Davis, & Lesmseister, 1983; Lewis & Epperson, 1991; Lewis, Epperson, & Foley, 1989; Lewis & Lewis, 1985; Martinez, 1991; Schneider, 1985; Tjeltveit, 1986) and the ethics of psychological practice (Corey, Corey, & Callanan, 1998; Daniels, 1994; Grimm, 1994; Hawkins & Bullock, 1995; Mitchell, 1993; Prilleltensky & Walsh-Bowers, 1999; Smith, McGuire, Abbott, & Blair, 1991; Sanders, 1997b; Tjeltveit, 1999; Worthington, 1993). There have also been a number of studies exploring therapists' beliefs and practice of ethics in counselling and psychotherapy (Gibson & Herron, 1990; Gibson & Pope, 1993; Golden & Schmidt, 1998; Haas, Malouf, & Mayerson, 1986; McMinn & Meek, 1996; Oordt, 1990; Pope, Tabachnick, & Keith-Spiegel, 1987; Pope & Vetter, 1992; Schwab & Neukrug, 1994). Some of the studies noted above mention the conflict therapists may feel between their personal values and the values of professional associations. Other articles report that Christian psychologists do experience some tension between their Christian moral values and the values of their professional association (Bersoff, 1995; Chapelle, 2000; Smith, McGuire, Abbott, & Blair, 1991). However, to my knowledge no study has looked at this question in depth and this gap in the 7 literature is an important area on which to focus. In this study psychology practitioners were given an opportunity to dialogue about the experience of values' conflict and how they have worked toward resolution of this tension. Participants were encouraged to share those things that have helped or hindered them in the process of resolving the conflict. The conflict in values of religiously oriented psychologists is a significant topic, especially at this time, when spirituality and religion are increasingly a focus in therapeutic practice. This is a new area in psychology and careful attention must be given to the ethics of integrating spiritual and religious values into psychological practice so that the best interests of clients are protected. If practitioners are unaware of how their religious values impact the therapeutic process, there is more likelihood of impinging on the rights and autonomy of clients. I hope that other psychologists and counsellors will benefit from the results of this study by an increased awareness of the possible value conflicts and by suggestions for resolving these conflicts. I believe this will have most relevance for Christian therapists with similar moral values, but I also hope that there will be some interest for psychologists who hold other strong moral values. Approach to the Study Qualitative research provides methodologies for obtaining rich descriptions of others' experience. It also involves studying things in their natural settings, and the interpretation of phenomena collected by the researcher in light of the meanings 8 people bring to them (Denzin & Lincoln, 2000). My reasons for conducting a qualitative study are consistent with many of those presented by Creswell (1998). First, my research question is a "what" question, which is best addressed using a qualitative methodology. Second, my topic needs to be explored because the variables are not easily identifiable and theories are not presently available to explain how therapists try to resolve tensions they experience between disparate value systems. Third, a detailed view of this topic would be helpful in which participants are invited to give a thorough account of their own experience rather than my trying to formulate a response questionnaire that would limit their input. Fourth, I have an interest in presenting the information in a literary style in which I locate myself in the research and bring my reflections and biases into the study, rather than pose as an objective observer. Fifth, I believe that my role as researcher is one of an active learner in the process. I am struggling with the issues I will be discussing with the participants. Thus, I am not positioning myself as an "expert" with all the answers; rather I want to tell stories from the participants' point of view. In conducting this study I wanted to use a qualitative method that would answer the question and was consistent with my epistemological assumptions. I ascribe largely to the postpositivist paradigm, which suggests that reality exists but cannot be easily apprehended (Morrow & Smith, 2000). For instance, I believe in the existence and reality of a divine order to the universe, however, it is difficult, if not impossible to fully comprehend the nature of the divine in a truly objective fashion. I also find social constructivist epistemology informative in the suggestion that our understanding of reality is based to a great degree on interpretive notions. 9 However, I do not totally adopt the social constructivist ontology of relativism, which suggests that all reality is constructed by individuals or social groups. Flanagan's (1954) Critical Incident Technique (CIT) is a qualitative method appropriate for the question being asked, and is also congruent with my epistemological assumptions. John Flanagan developed this method initially for job analysis in aviation psychology, but it has been modified and used extensively in other areas of psychological research (Cohen & Smith, 1976; Rimon, 1979; Dachelet, Wemett, Garling, Craig-Kuhn, Kent, & Kitzman, 1981; McCormick, 1994; Butterfield, 2001; Wong, 2000; Woolsey, 1986). CIT asks participants to reflect on and articulate the resources or factors that help or hinder in a particular process, which, in this study, provides a broad range of incidents that help or hinder psychologists as they seek to resolve conflicts in values. Such information is valuable in providing insight and concrete suggestions to others dealing with similar values tensions. Data were collected from evangelical, Christian psychologists using interviews, which were audiotaped and transcribed. Data analysis consisted of extracting the helping and hindering incidents within each scenario, sorting them into categories with similar content, and labeling each cluster with a descriptive title. These categories were formed and reformed, named and renamed in an inductive process, based on researcher insight and feedback from validation procedures. Several procedures were conducted to ensure the soundness of the categories. These included asking experts in the field to review the categories for relevance and usefulness and conducting a second interview with participants (by phone or email) 10 to solicit their feedback as to how well the researcher sorting and recording of data fit with their experience. Other validation procedures consisted of asking independent raters to classify a random selection of incidents into the appropriate category, calculating participation rate for each category, and comparing the findings with relevant literature to assess the theoretical agreement. Definition of Terms A s previously stated, a psychological definition of the term values will be used to describe "what people value, judge to have value, think to be good, or desire" (Tjeltveit, 1999,p. 85) and this will focus on cognitions, affect, and behaviours that embody questions of "right" and "wrong." Moral and ethical are often used as interchangeable words. Some delineate ethics as a broader construct which not only involves questions of "right" or "wrong" but also those nonmoral questions of goodness and value, such as happiness and mental health (Tjeltveit, 1997). Professional codes tend to use ethics in the narrower sense of moral and it is in this sense that the term ethics will be used in this paper. The terms spirituality and religion are sometimes used interchangeably but I will be using what I have found to be the most common distinction in the literature (Ingersoll, 1994; Mack, 1994). I will be defining spirituality as a broad, multidimensional construct that is primarily about relationship and connectedness: to oneself, to others, to nature and/or to an Ultimate Being. Religion is often thought 11 of as the organized framework through which spirituality is expressed and it is in this context that I will be describing a "Christian" religious perspective (Houston, Bufford, & Johnson, 1999). The Christian perspective refers to that of an evangelical Christian. In this study, this is defined by the Statement of Faith of the Christian Association for Psychological Studies (CAPS): Belief in God the Father, who creates and sustains us; Jesus Christ, the Son, who redeems and rules us; and the Holy Spirit, who guides us personally through God's inspired Word, the Bible, our infallible guide of faith and conduct, and through the communion of Christians. Considering issues from a Biblical perspective implies that this is the Bible interpretation adopted by mainstream evangelical Christians. It is sometimes difficult to differentiate between counsellors, therapists, psychotherapists, and psychologists. I will use the terms psychologist, therapist, and psychotherapist interchangeably. Also the terms psychological practice, therapy, and therapeutic practice, setting, etc. will be used interchangeably. The terms counsellor or counselling will be limited to reflect usage in the literature or use by participants in the interviews. 12 Chapter 2 - Literature Review In this chapter, I will review the relevant literature that provides a background for my research question, which is "What factors help or hinder evangelical Christian psychologists in dealing with the tensions they experience between their religious moral values and the ethics of professional psychological practice as embodied in professional ethics codes? I will look at some of the conceptual and research literature on ethics, ethical decision-making, values, and spirituality/religion in psychological practice. I will then provide a context for my research question with a discussion about religious values, ethics in religious practitioners, and relate this specifically to Christian therapists. Ethics and Ethical Decision Making Psychologists and counsellors are faced with ethical concerns and decisions routinely in their day-to-day practice. The study of ethics traditionally comes from a branch of philosophy that deals with moral judgments, as questions of what is "right" or "wrong," "good" or "bad," "acceptable" or "unacceptable" (Koocher & Keith-Spiegel, 1998). Ethics applied to psychology is often narrowed to three areas: ethics codes, principle ethics, and virtue ethics. Codes of ethics are formulated by professions as part of the process of professional identity development in order to promote commitment to fundamental values and to inform and protect the public by giving them some assurance of the high standards of those professionals who adhere to the code (Bersoff, 1995). Psychology and counselling ethics codes are 13 generally formulated by a group within the profession endorsed to carry out this task. Even though there is usually a process in which the whole membership can have some input, codes are generally constructed by a committee within the organization based on the consensus values of the entire group (Bersoff, 1995). Bersoff (1995) notes that all values and beliefs of members are not represented in an ethics code and that there may be defensible occasions when a psychologist might violate the ethical rules of his/her professional association. This may happen when a psychologist believes that he/she must follow a higher moral rule or value, such as a religious value. Kitchener (1984) suggests that higher-level norms, called principles, may mitigate some of the problems encountered from the inadequacy of professional codes. Principles are more general and fundamental than moral rules or codes and serve as their foundation. Because ethical codes may be too broad in some cases and too narrow in others, ethical principles both provide a more consistent framework within which cases may be considered and constitute a rationale for the choice of items in the code itself (p.46). She identified five important principles (autonomy, beneficence, nonmaleficence, justice, and fidelity) as most critical for appraising ethical concerns in psychology. Ethical decisions are based on consideration of the ethical principles involved, although it is not always clear how to proceed when ethical principles conflict. Virtue ethics focuses on the development of stable character traits that have merit or worth and are often related to matters of right conduct (Meara, Schmidt, & 14 Day, 1996). Virtue ethics asks the question, "Who shall I be?" rather than the question of principle ethics, "What shall I do?" Meara et al. (1996) suggest that developing the virtues of prudence, integrity, respectfulness, and benevolence will complement the use of principles and codes in the process of ethical decision-making. Most religions also focus on the concept of a virtuous character and the religious perspective may differ from the professional view about what virtues are to be encouraged. Most of the research on ethics in psychological practice has focused on the implementation of ethical codes. Pope and Bajt (1988) conducted a survey in which they asked the question: "In the most serious, significant, or agonizing instance, if any, what law or formal ethical principle have you broken intentionally in light of a client's welfare or other deeper value?" (p. 828). A majority of the respondents (57%) reported such occurrences, but the focus of the study was on the incidents themselves, with no discussion about how this supported client welfare or a deeper personal value. Similar survey studies were done by Golden and Schmidt (1998), in which mental health practitioners were asked about perceptions of unethical practice, and by Pope and Vetter (1992), in which psychologists were asked to describe ethically challenging or troubling incidents that they or a colleague had encountered. Again, the results of each of these studies focused on description of specific incidents, with little discussion of how the context may have related to psychologists' ethical beliefs or practice. 15 Other survey studies of ethical misbehaviour in mental health practitioners have been conducted in the past few years. Pope, Tabachnick, and Keith-Spiegel (1987) surveyed psychologists about the occurrence of 83 behaviours in their practices and their beliefs about how ethical these behaviours are. This survey design was repeated by Gibson and Pope (1993), collecting data on counsellors (members of the American Counselling Association), modifying the questionnaire to address issues specific to counsellors on 88 items. Haas, Malouf, and Mayerson (1986) investigated the choices made by clinicians when faced with vignettes of ethical dilemmas and to rate the frequency and seriousness of 17 prescribed ethical issues that could be encountered in clinical practice. In all of these studies, behaviours were categorized into those that were believed to be ethical or not ethical. For the most part, the results of each of these studies were summarized into percentages of participants falling into the categories specified. However, there were only two items in which there was universal agreement about the ethical nature of the behaviours (not engaging in either erotic activity or sexual contact with a client) in the Gibson and Pope (1993) study, none in the Pope et al. (1987) study, and none in the Haas et al. (1986) study. Gibson and Pope (1993) spoke of items in which there was an overwhelming endorsement of either ethical or unethical behaviour, with 90% of participant agreement being the line drawn to make this claim. In this type of study, in which the researchers predetermine all of the items, there are no reasons given as to why the 90% agree or why the other 10% see things differently. 16 In a survey of 102 mental health practitioners, Smith, McGuire, Abbott, and Blair (1991) investigated the rationales therapists use to justify differences between what they felt they should do and what they would do when presented with a series of ethical vignettes. With each vignette, participants marked choices for what they should and would do and then chose one of eight rationale statements for each response. Analysis showed some discrepancy in the should and would responses, especially in the nonlegal vignettes. The rationale statements were analyzed only for codified (e.g., upholding the law or code of ethics) or non-codified responses (e.g., intuition, upholding moral/personal values, protection of reputation), and it was difficult to differentiate what were the most common rationales. This research was also in the form of a questionnaire with forced choices and respondents had no opportunity for substantial explanations in which they could explain more fully their choices and the reasons behind them. Walker, Pitts, Hennig, and Matsuba (1995) tried to overcome the limitation of predetermined items by interviewing 80 participants from a variety of backgrounds and asking them to discuss moral dilemmas from their own life experience. The interviews were fairly structured, with each person being asked 86 questions, including queries about a recent typical moral dilemma and their most difficult real-life dilemma. An interesting theme that emerged from the discussion of the resolution of these dilemmas was that many individuals relied on spiritual and religious beliefs and, for some, morality was embedded in and governed by their faith. There were some limitations to this study, in that the methodology, including analysis of findings, was not adequately described and there was a limited number 17 of participants. This makes any generalizations difficult; however, this result is consistent with those of other authors who suggest that morality is based on religious values for many people (Bergin, 1980; Chapelle, 2000, Richards, Rector, & Tjeltveit, 1999; Bergin, Payne, & Richards, 1996). Values in Psychological Practice The study of ethics is intricately related to values and ethical codes are based on values (Tjeltveit, 1992). Psychotherapy was once considered a value-neutral activity and psychologists were encouraged to ensure that they did not promote their own values and thus impinge on client's rights of autonomy (Bergin, 1980; Hawkins & Bullock, 1995). In the past several decades it has become apparent that psychotherapy is a value-laden process and that it is virtually impossible, as a therapist, not to communicate one's values to clients to some degree (Bergin, 1980; Richards & Bergin, 1997; Tjeltveit, 1986). Tjeltveit (1992) asserts that therapists cannot help but bring their ideas about what is good, right, and virtuous into the therapeutic setting and thus exert some influence on clients concerning these ideas. In two studies reported by Bergin (1980), even Carl Rogers, who promoted freedom of the individual, was shown to systematically shape behaviour of clients by rewarding and punishing expressions that he liked or did not like. It was concluded that Rogers' values regulated the content and structure of sessions and thus impacted the outcomes. In general, Tjeltveit (1986) asserts that it is common for clients to adopt some new values during the course of 18 therapy, specifically those of the therapist. He uses the term "value conversion" (Tjeltveit, 1986, p. 516) to denote the unilateral nature of this influence process in therapy. Lewis and Walsh (1980) conducted a study in which they were trying to determine if clients could perceive counsellor values from both implicit and explicit examples of counsellor/client interaction around the issue of premarital sex. The participants generally seemed unaware of the counsellor's implicit attempts to influence a client to either go ahead or refrain from sexual activity. The researchers also noted that when the clients knew the counsellor's values through explicit information, the counsellor was perceived as more attractive and trustworthy by clients with similar values. There were several limitations to this study, including the use of analogue student clients, inadequacies of the psychometric measures used, and the interpretation of significant results based on F-tests from A N O V A s and MANOVAs rather than effect sizes. However, this study does suggest some interesting areas for further research, including the introduction of information to clients about counsellor values and the effect this may have on the therapeutic process and outcome. This discussion raises ethical issues inherent in the phenomenon of therapist influence in altering client values and the restriction this imposes on client autonomy. With the growing recognition and inclusion of spirituality into the therapeutic process, the whole area of client conversion to therapist religious values is highlighted (Bergin, 1980). Religion is not alone in stimulating this debate, but rather any value system that is overt in nature, such as strong moral or political views of 19 the therapist. The ethical problems inherent in this possible value conversion are delineated by Tjeltveit (1986). Foremost is the reduction of a client's freedom to choose their own values by an overt imposition of therapist values, moralism (the conveyance of a censorious attitude), propagandizing (the promotion of limited value options), or failure to provide clients with adequate information about therapy. For example, if a therapist gives some indication, even subtly, that there is something wrong or inappropriate with a client who believes that homosexual relations are permissible, then the therapist may be imposing his/her own moral values, thus reducing the client's freedom to choose. Therapists may also fall into the trap of value imposition by not supporting a client who is exploring the need to talk with a minister or pray at home for guidance about a particular situation. Clients have the right to be supported in their religious beliefs and desire to use spiritual interventions. On the other hand, therapists who use spiritual interventions (or any other uncommon interventions) need to provide enough information for the client to make an informed choice about whether or not to participate in such interventions (Kelly, 1995; Sanders, 1997a). It becomes essential that relevant values become explicit and that therapists include some comments about this in the informed consent procedures, so that client autonomy is maintained. A number of studies have been done examining the effects of pretherapy information about counsellor values (using counsellors who hold strong values), in which the described value position impacted on clients' perceptions of similarity to the therapist, confidence in the therapist's helpfulness, and willingness to see the therapist (Enns & Hackett, 1990; Epperson & Lewis, 20 1987; Lewis, Davis, & Lesmeister, 1983; Lewis & Epperson, 1991; Lewis, Epperson, & Foley, 1989; Lewis & Lewis, 1985; Schneider, 1985). One of the hypotheses emerging from these studies is that the provision, by counsellors, of explicit pretherapy information regarding values would enable clients to form a more complete picture of a counsellor and use this information to decide whether or not to go into counselling with that therapist. Bergin, Payne, and Richards (1996) contrast this explicit therapist stance to one of ethical relativism, which they suggest is not desirable. Current guidelines and recommendations for multiculturally sensitive therapy [including religious counselling] are problematic because they implicitly advocate an ethically relativistic therapist stance that suggests the worldviews and values of different cultures are equally valuable and true. Although it is important for therapists to be tolerant of differences and to respect clients' rights to hold values that differ from their own, an ethically relativistic position implies that therapists should agree with all client values or accept clients' values as equally good or valid...Therapists who adopt a relativistic stance cannot logically challenge destructive client values because all values are assumed to be equally worthwhile (p. 300). Bergin, Payne, and Richards (1996) note that the difficulty does not lie so much in holding strong values, but in recognizing the impact these may have on clients and in making these explicit to the client to promote informed choice and autonomy. The Canadian Psychological Association guidelines (1991) emphasize the need for psychologists to be aware of the impact of their values on clients: 21 They [psychologists] also engage in self-reflection with the purpose of determining how their own values and social context (e.g., culture, ethnicity, colour, religion, gender, sexual preference, physical and mental ability level, age, and socio-economic status) influence their actions, interpretations, choices and recommendations (Principle II: Responsible Caring). Haidt and Hersh (2001) conducted a study on sexual morality using self-described liberal or conservative participants. One of the goals of the study was to determine if there were differences between these two groups in their use of moral domains as described by Shweder, Much, Mahapatra, and Park (1997): ethics of autonomy, ethics of community, and ethics of divinity. Ethics of autonomy (EOA) is based on considerations of harm and rights in which people have a right to do what they wish provided they do not hurt others. Ethics of community (EOC) involves concerns about maintaining and protecting the social order and social system. It contends that traditional roles of the family and community ought to be a certain way and they must be respected. Ethics of divinity (EOD) focuses on issues of sacredness, purity, and living according to the belief that humans are created in God's image and designed for a specific purpose. Haidt and Hersh (2001) hypothesized that liberals would likely limit their moral outlook to ethics of autonomy, in which no action is wrong, unless it directly harms another. They postulated that conservatives would also include ethics of E O C and EOD, as well as autonomy, and that all unusual sexual practices would be condemned. The participants were presented with several scenarios that violated several classes of sexual norms: homosexual behaviour, unusual masturbation, and 22 consensual sibling incest. The results generally supported the hypothesis stated above in that liberals showed a harm-based morality, largely limited to EOA, while conservatives more often included E O C and EOD as well as EOA. However, these differences tended to be dependent on the scenario type, in which the difference was greatest for homosexual behaviour and minimal on the incest scenarios. There were several limitations to this study, including a small number of participants who were all students from one university community. The division between liberal and conservative was based on self-report and was not clearly articulated. However, this study indicates that people judge issues based on a predominant moral domain or moral values. When a contentious issue, such as homosexual behaviour, is presented it should be remembered that all sides are morally motivated. It seems to be part of the nature of moral argument that one's opponents are seen to be motivated by evil. Conservatives see liberals and homosexuals as driven by the immoral force of "perverted" sexual desire. Liberals see conservatives as motivated by the immoral forces of hatred, homophobia, and narrowmindedness. But such moralization and demonization obscure the true nature of the conflict, and make moderation or compromise into a moral failing - one should not negotiate with the devil. It is more accurate, and certainly more conducive to cooperation, to acknowledge that both sides are driven by their moral commitments...The two sides differ in their conceptions of the good, not in the goodness of their motivations (Haidt & Hersh, 2001, p.217). A recent set of articles by Rosik (2003a) and Green (2003) illustrate the point 23 that morality is based on one's value framework. Rosik reviewed the treatment of gay, lesbian, and bisexual individuals who desire to increase their heterosexual tendency. Green (2003) wrote a commentary on Rosik's article discounting any value in change-oriented therapies and suggesting that these therapies are rooted in societal prejudice and homophobia. Rosik's (2003b) response to Green's commentary suggests that Green is not forthcoming about his own value framework and moral domain, which is consistent with an ethics of autonomy. Rosik notes that EOD-based biases may be more identifiable than those of E O A by practitioners and academics who generally reason within an EOA moral framework. "Green may only see religious bias when evaluating clinical efforts to increase heterosexual potential. Thus, it is probably easier for him to see the effects of moral assumptions in my writings than his own" (Rosik, 2003b, p. 44). Rosik encourages all clinicians and researchers to openly identify the moral values that lie beneath their work. Resolving Value Conflicts Values often come into conflict and the resolution of these conflicts has been a focus of study in several areas of psychology. Ethical decision-making has developed to address conflicts specific to the field of ethics. Other areas of psychological inquiry that focus on value conflicts include values clarification, and cognitive dissonance theory. Each of these will be addressed in this section as a means to identify current conceptions of resolving value conflicts. 24 Ethical decision-making Ethical decision-making is a process for solving ethical dilemmas that often arise when values come into conflict (Kitchener, 1984; Rest, 1984). Therapists are encouraged to rely on critical thinking rather than intuition or "gut feelings" and the steps in this cognitive process are clearly laid out (Canadian Counselling Association, 1999; Canadian Psychological Association, 1991; Cottone & Claus, 2000). Betan (1997) notes that these ethical decision-making models do not fully capture the way most people approach day-to-day ethical practice, as they do not take into consideration the context or personal values. He proposed a hermeneutic model based on the principle that ethical analysis is an interpretive process situated in the context of human relationships. Ethical principles reflect assumptions and values that are interpreted in light of one's personal and cultural perspective. In applying a hermeneutic understanding of ethics, training must address three significant issues of professional development: (a) aiding a therapist in recognizing and tolerating the inherent ambiguity and conflict of ethical matters in psychotherapy; (b) fostering a therapist's awareness of the personal and moral values, as well as the competing demands, that may arise in confronting an ethical dilemma; and (c) promoting a therapist's ability to make and implement sound ethical and clinically appropriate judgments based on an awareness of the interplay of subjective, situational, and ethical considerations (Betan, 1997, p. 361). 25 Cottone (2001) took this relational perspective even further by proposing a social constructivist model of ethical decision-making. He suggested that making decisions is not an individual psychological process, but rather a social process involving interaction with at least one other individual. Ethical decision-making takes place within interactive processes of negotiation, consensus building, and arbitration. Values clarification Values clarification (VC) is a process which began in the 1960's to help people who seemed unclear about their values gain clarity and, from this process, attain a better perspective on meaning and purpose in their lives (Kinnier, 1995). V C reached its height of popularity in the 1970s, during the heyday of humanistic philosophies that promoted self-fulfilment, freedom, personal responsibility, and respect for alternative lifestyles. Kinnier (1995) suggests that the philosophical base of V C was consistent with the values of this period. In the 1980s, V C began to decline in popularity after major criticism from within and outside the profession of psychology. One of the critiques came from conservative religious leaders who argued that V C promotes ethical relativism in its admonition to look within one's self rather than to a Supreme Creator for guidance on moral issues. Kinnier suggests that V C be revitalized and reconceptualized as a beneficial intervention to help people identify and resolve value conflicts. V C interventions have traditionally considered values in the abstract realm rather than in the context of real life events. Kinnier asserts that a more appropriate goal of V C is to help people resolve 26 specified values conflicts, one at a time, within the context in which they occur, using strategies that are relevant for both the person involved and the conflict situation. Cognitive Dissonance Theory A third mode of conceptualizing values conflicts is through the lens of cognitive dissonance theory. Leon Festinger (1957) first articulated the theory in his book "A Theory of Cognitive Dissonance." He postulated that humans have a need for consistency among related cognitive elements. When a person becomes aware that two related cognitions are mutually inconsistent, an uncomfortable psychological feeling is created (dissonance), and this will lead to change in one or both cognitions to restore consistency (Baron, Byrne, & Watson, 1998; Harmon-Jones & Mills, 1999; Prislin & Pool, 1996). This theory most often addresses dissonance in attitudes and behaviours; however, this is related to values in that attitudes are based on personal values. When dissonance occurs, a person is motivated to change by various mechanisms (Baron, Byrne, & Watson, 1998). First, the person may change attitudes or behaviours so that they become more consistent with each other. Second, a person may acquire more information that changes the perceptions of the inconsistencies. Third, a person may minimize or trivialize the attitudes or behaviours that produce the disparity and this leads to trivializing the inconsistency itself. In the literature review conducted for this proposal, there are no research studies that make specific mention of psychologists using any of these modes 27 (ethical decision-making, values clarification, or cognitive dissonance theory) in resolving values' conflicts. It is interesting to speculate which, if any, of these ways of approaching the resolution of tension between conflicting values that psychologists with strong, religious moral values utilize. Spirituality and Religion in Psychological Practice Values, for many people, are based on religious practices and beliefs, however, it is only in the past 20 years that this relationship has been openly acknowledged and investigated (Bergin, 1980; Walker, Pitts, Hennig, & Matsuba, 1995). In this section, I will review the historical interface between psychology and religion over the past century, which involves a movement from almost complete separation, to the more recent efforts to understand the role that religion and spirituality play in psychological theory and practice. I will then describe the role of religious values in the therapeutic process and, more specifically, the research on Christian religious values in psychotherapeutic practice. The connection between spirituality or religion and psychology is one that can no longer be ignored by clinicians in the field (Bergin, 1980; Bishop, 1992; Hawkins & Bullock, 1995). Historically, spirituality and religion were largely neglected in the psychological literature, apart from a few theorists like James (1997), Jung (1938), Allport (1950), and Frankl (1959). Richards and Bergin (1997) suggest that there are numerous influences that contributed to this alienation. Modern psychology developed in the late 19 t h and early 20 t h centuries, during a time 28 when the "Age of Science" was pre-eminent and challenging the previously dominant worldview of religious tradition and authority as the source of truth. Many people believed that science, not religion, would unlock the mysteries of the universe. The philosophical underpinnings of science, during this time, were antithetical to religious experience. Naturalism (the belief that the happenings of the world can be explained and understood without including a Supreme Being), determinism (human behaviour is caused by forces apart from human control), universalism (natural laws are context free, apply across time, space, and persons, and must be generalizable and repeatable), and reductionism (human behaviour can be understood by reducing it into smaller parts), were some of the prime metaphysical assumptions of the time. The major epistemological assumptions of science were positivism (knowledge is restricted to discernible facts and their interconnections), and empiricism (the only reliable source of knowledge comes through sensory experience). Many of these modernistic, naturalistic assumptions were supported by earlier psychological theorists such as Freud, Watson, Skinner, Wolpe, Bandura, Rogers, and Ellis. However, in the second half of the 20 t h century, these assumptions were questioned and their influence gradually weakened. Richards and Bergin (1997) outline some of the influences that have contributed to the changing Zeitgeist: a) the rise of postmodernity in which human behaviour is seen as meaningful only in context, and knowledge and truth are seen as interpretive creations by people of similar culture, and language; b) the renewal of interest in spiritual phenomenon in the popular culture; c) the finding of a positive correlation 29 between religiosity (beliefs and behaviours) and many indicators of emotional and social adjustment; d) the rise of the multicultural counselling movement highlighting the need for greater awareness and tolerance of diversity that exists in the world, including religious diversity; e) the movement toward eclecticism in psychotherapeutic practice opening the door for non-traditional techniques, including spiritual interventions; and f) the increasing recognition of the importance of values, including religious values, in the therapy process. Jones (1994) makes a substantive case for a mutual and respectful relationship between religion and the science and practice of psychology. He suggests that, although there are noteworthy distinctions between religion and the science of psychology, there are also many similarities. Both grapple with facets of human experience - the nature of human beings, meaning making, morality, and suffering. Jones goes on to propose a new model for the relationship between religion and psychology. He suggests three forms of interaction within this model. The first is a critical evaluation mode in which researchers and practitioners examine scientific theories and paradigms, filtering them through their own religious world view and assumptions, and adopting them only so far as there is a "fit" between scientific and religious. The second is a constructive mode in which science is open to religious belief, recognizing that this spiritual worldview may allow for a new way of seeing things that would enrich the understanding of data and theory. Finally, Jones suggests a dialogical (vs. unilateral) mode in which both religion and science must be open to the other and prepared to change as they engage in constructive dialogue. 30 Jones (1994) believes that all theory is value laden and he points out the necessity of making values explicit. If scientists, especially psychologists, are operating out of worldview assumptions that include the religious, and if the influence of such factors is actually inevitable, then the advancement of the scientific enterprise would be facilitated by making those beliefs explicitly available for public inspection and discourse (p. 193). The American Psychological Association (APA, 2002), in its ethics code, has been explicit in this regard by listing religion as one of the areas of diversity that requires training, consultation, or supervision in order to ensure professional competence and eliminate discriminatory practices (Principle D: Respect for People's Rights and Dignity). The American Psychological Association has also demonstrated its commitment to the inclusion of religion and spirituality in psychological theory and practice by the recent publication of four books: "Religion and the Clinical Practice of Psychology" (Shafranske, 1996); A "Spiritual Strategy for Counseling and Psychotherapy" (Richards & Bergin, 1997); "Integrating Spirituality into Treatment: Resources for Practitioners" (Miller, 1999); and "Handbook of Psychotherapy and Religious Diversity" (Richards & Bergin, 2000). With the encouragement, or perhaps directive, that religious values be considered in therapeutic interactions, it becomes important that therapists are prepared to handle this area in an ethically appropriate way (Hawkins & Bullock, 1995). Hawkins and Bullock (1995) suggest that this entails therapists acquiring 31 professional competence in religious issues through training, becoming aware of their own values and beliefs and how these may impact on clients, being open with clients about beliefs and values, and being aware of treatment alternatives to ensure the best client/therapist "fit." Psychologists who neglect to assess the role of clients' religious values may limit their ability to be helpful to clients who have a world view which incorporates such values; this would constitute an ethical error of omission (Bishop, 1992). Hawkins and Bullock (1995) suggest that religious expectations and concerns are best addressed at the beginning of therapy as part of the informed consent procedure and continually throughout therapy when it is relevant to the process. These authors suggest that the concern about therapist values and convergence is best handled by an open discussion with clients. Bergin (1985) concurs: It is vital that we be more explicit about values because we use them, however unconsciously, as a means of therapeutic change. Although we may have been hesitant about this for fear of becoming manipulators of morals, being explicit actually protects clients. The more subtle our values, the more likely we are to be hidden persuaders. The more open we are about our view, the more choice clients will have in electing to be influenced or not to be influenced (p. 107). Haug (1998), in writing about the ethical considerations of including a spiritual component in family therapy, noted client autonomy as one of the main concerns. He notes the difficulty that clinicians who hold strong religious views can 32 have in not judging or proselytizing clients who hold divergent views. This may be especially true in the case of a "Christian" therapist seeing a "Christian" client, when there are many beliefs within Christendom and many forms of "Christian" therapy (Worthington & Gascoyne, 1985). Two surveys have been conducted on ethical concerns of therapists with explicit religious positions. McMinn, Meek, and McRay (1997) surveyed 498 Christian counsellors about their ethical beliefs and practices using a structured survey instrument. Their findings indicated that Christian counsellors are aware of ethical standards and generally follow these conventions. In response to the item about treating homosexuality as pathological behaviour, 36% believed that this is ethical practice and 24% said they experience this in their practice "fairly" or "very" often. There was no qualitative aspect to this study to interpret this in view of counsellor beliefs about the interaction of this practice with other professional codes of ethics. Another limitation of the study is that the respondents were homogeneously classified as "Christian" counsellors by their membership in the American Association of Christian Counsellors, with no explanation of what it means to be a Christian counsellor. Richards and Potts (1995) surveyed 215 Mormon therapists to find out what spiritual interventions they used, the effectiveness of these, perceptions of positive and negative outcomes from using these, and their attitudes about the ethical appropriateness of using these religious interventions in their professional work. The survey instrument included both structured and open-ended questions. Most of the therapists noted that, if used appropriately, spiritual interventions (the most 33 common noted were prayer and teaching spiritual concepts) can significantly enhance the efficacy of therapy but they also indicated an ethical concern about the danger of imposing religious values on clients in the use of these interventions. Seventy-three percent of the respondents believed that there are some interventions that should never be used in therapy sessions, including laying on of hands, encouraging clients to confess, and client/therapist in-session prayer. They noted the importance of assessing clients' beliefs and obtaining clients' permission before using any spiritual interventions. Although there was a small qualitative component to this study, the questions and answers were limited and there was no detail about how the therapists avoided imposing their values. Religious Coping When values come into conflict a person will experience some stress. There is a growing body of research into the use of spiritual practices for coping and well-functioning, which includes dealing with these value conflicts. Coster and Schwebel (1997, p. 5) describe well-functioning as "the enduring quality in one's professional functioning over time and in the face of professional and personal stressors." Many studies have been done in which religion or religious variables were listed very high on measures of coping (Colston, 1994; Jenkins & Pargament, 1995; Maton, 1989; Mcintosh, Silver, &Wortman, 1993; Pargament et al., 1988; Pargament etal . , 1990; Pargament et al., 1994). 34 Coping can be conceptualized according to Lazarus and Folkman's model as a four-stage process: (1) the occurrence of a life event; (2) constructing primary and secondary appraisals of the event (this involves evaluations of the meaning of events and one's ability to cope); (3) engaging in coping behaviour or strategies; (4) outcomes (Park & Cohen, 1992; Pargament et al., 1990). Pargament et al. (1990) indicate that religion can be part of each element of the coping process: (1) the life event can be of a religious nature such as baptism, marriage, and funerals; (2) religious appraisals can be used as a source of explanation for life events; (3) religious coping activities can be used such as prayer, confession to God, and support from clergy; and (4) the outcome of the coping process may be religious, e.g., increased religious commitment. Park and Cohen (1992) state that religion's role is especially important in the appraisal and coping behaviour stages. Lazarus (1993) wrote about the need for people to make meaning in situations to enable them to cope: "I am confident that personal meanings are the most important aspects of psychological stress with which the person must cope, and they direct the choice of coping strategy" (p. 244). Making meaning has a lot to do with religious beliefs and, although Lazarus did not make this connection explicit in his writings, others have picked up this thread. Beliefs are "preexisting notions about reality [and] form a bias or lens through which the facts of the environment are seen, and they lead to an understanding of the meaning of these facts" (Park & Cohen, 1992, p. 188). Religious beliefs offer a variety of meaningful explanations about significant life events. 35 A central assumption in coping is that appraisals influence the specific coping strategies a person might use in a particular situation. Traditionally, most coping instruments assess religious coping with a few global items or ignore it altogether (Park & Cohen, 1992). In contrast, a variety of religious coping strategies have been identified (Jenkins & Pargament, 1995; Mcintosh et al., 1993; Pargament et al., 1988; Pargament etal . , 1990; Pargament etal . , 1994; Robinson, 1994). The most commonly cited are prayer, attendance at church, and church support (including consultation with clergy). Case and McMinn (2001) reported on spiritual coping and well-functioning in psychologists. Surveys were sent to 600 psychologists, randomly selected from the A P A membership list, half whom had indicated an interest in religious issues. Four hundred surveys were returned and analyzed. The respondents were divided into "more religious" and "less religious" groups based on the extent of their involvement in a church or synagogue. The two highest ranked coping items for the more religious psychologists were "prayer or meditation" and "attending religious services," demonstrating that spiritual resources are the first resource for dealing with distress. The authors note: "students entering graduate school with devout religious beliefs would do well to integrate those with beliefs into their style of coping with professional work - something that will require the help of spiritually informed mentors and professors" (p.39). 36 Christians in Clinical Practice Religious values have important implications in all areas of psychological theory and practice. There are many psychologists in clinical practice who hold religious values and view these values as the foundational guiding force in their lives (Johnson, 1998). Therapist values will be explored further in this section within the context of Christian religious values. The Christian psychology and counselling movement has grown considerably in the past 30 years (Houston, Bufford, & Johnson, 1999). There has been much discussion, even controversy, about the nature and characteristics of a counselling movement that designates itself as "Christian." However, since humans cannot study themselves apart from their assumptions and core beliefs about human nature (Johnson, 1998; Jones, 1994), the fundamental beliefs of Christians must be taken into consideration in the understanding of psychological truth from this religious perspective. There could, then, be something important at stake in taking with utmost seriousness our [Christian] community's unique beliefs' regarding human nature (e.g., the image of God, sin, the role of the Holy Spirit in conversion and Christian character development, and so on). Such beliefs will affect our understanding of psychology . . . and enable us to move beyond the limitations of the basic belief framework of modern psychology (i.e., naturalism) to understand human nature more accurately (more like God does). Such a project would not lead our community to neglect the rich body of theory and research of modern psychology. . . But it requires 37 deconstructing that tradition and interpreting it more consistently from a Christian standpoint, as we use it critically to enrich our own. (Johnson, 1998, p. 292). Johnson goes on to suggest that Christian psychologists should consider that their primary identity is derived from membership in the Christian community, with a secondary identity associated with the psychological community. Houston, Bufford, and Johnson (1999) conducted an exploratory study to investigate what Christian therapists believe are the most prominent features of Christian psychotherapy and what these practitioners believe undergirds the change process in Christian therapy. This study consisted of a survey questionnaire returned by 164 Ph.D. or Psy.D. practicing members of the Christian Association for Psychological Studies (CAPS). The results of a 7-point Likert scale showed that respondents believed that the most salient components of Christian counselling are: a) God is the primary healer and the counsellor is God's agent (mean 6.72, SD .79); b) the personal faith of the counsellor (mean 6.72, S D .64); c) the Holy Spirit is present and active (mean 6.67, SD .88); d) Christian values guide means, ends, and motives (mean 6.65, SD .83; and e) a Christian world view (mean 6.51, SD 1.05). When the participating psychologists were asked to identify the active ingredients which contribute to client change in Christian therapy, the most salient source of gain was viewed as "God, Jesus Christ, or the Holy Spirit brings about change" (p. 246), followed by "instilling a sense of hopefulness or hope in God" (p. 246), "a God-ordained world view," and "biblical truth"(p. 247). There are some 38 limitations to this study - namely the group of C A P S psychologists may not be representative of all Christian psychologists and the survey questionnaire allowed a limited choice of responses, rather than asking the participants more open-ended questions. However, it appears, at least among this group of Christian psychologists, that they hold fundamental beliefs and values of a Christian religious faith and that these values are linked to the practice of psychology. Christian therapists (i.e., those who hold an evangelical perspective) hold strong values about many issues and it is inevitable that these values will permeate their psychological practice. Tjeltveit (1986) says: Isn't value influence inevitable, though? Yes, it is. Therefore, Christian therapists working in the public arena ought to think as carefully as possible about ideals for human functioning so that their inevitable (and appropriate) influence will be as consistent with Christian ethics as possible, (p. 95) Christian ethics are based on a Christian worldview in which adherence to scriptural principles is paramount (Beck & Matthews, 1986). Often there is correspondence between professional and Christian codes of ethics but there can also be significant differences. It is generally agreed that Christian mental health professionals should abide by the professional codes that govern their practice (Tjeltveit, 1997); however the relationship between Christian ethics and professional ethics is complex. Tjeltveit (1997) describes three approaches Christians have to professional ethics codes. The first is a rival approach in which Christian ethics and professional codes are seen as incompatible and practitioners must decide if their allegiance is 39 with the codes ("the world") or with Christ. Tjeltveit suggests that it is unlikely that Christian therapists who hold this perspective will join a professional association governed by such a code. The second approach posits that there is no difference between ethics codes and Christian ethics, that professional codes are based on Christian values. This view negates the idea of a distinctively Christian ethic for therapists. The third position acknowledges some differences but maintains a deep respect for both Christian and professional ethics, and that, with thoughtful contemplation, a Christian need not be wholly constrained by professional ethics codes. Maloney (1986), points out some of the differences between professional ethics codes (e.g., those of the American Psychological Association, 1992 & 2002, and the American Association for Marriage and Family Therapists, 1995), and those for the Christian Association for Psychological Studies - C A P S (King, 1986), an organization for Christian mental health professionals. The C A P S code recognizes the Bible as providing a foundation for professional behaviour, requires that members affirm a statement of faith, recognizes professional activities as a part of the Christian call to service, articulates "love" as the basis of professional service, and voices a high regard for the integrity of the family. The C A P S code, thus, emphasizes strong Christian values. There have been no studies done which examine the interplay between Christian values and professional ethics codes but one might question how Christian psychologists might handle issues like divorce or same-sex couples, given the emphasis on the integrity of the family and the proscription of these behaviours 40 in Christian ethics. Pope and Vetter (1992) noted a concern by one respondent who was particularly troubled by APA 's view of homosexuality: My professional association, the APA, has said that my religious beliefs (e.g., that homosexual acts are wrong) are unethical. Therefore, should I quit the A P A or my religion? (p. 406) This reference does not explicitly identify this psychologist as "Christian," but this psychologist's concern is in keeping with a biblical perspective on homosexual behaviour (Grenz, 1998). Oordt (1990), in a survey of Christian psychologists, noted that a survey item about treating homosexuality as pathological was classified as a difficult judgment for participants (indicated by at least 20% of the sample saying "don't know/not sure" about the degree to which this behaviour is ethical). Oordt (1990) explains this as the confusion Christian professionals may feel when caught between a church, which generally regards homosexuality as deviant, and a professional association that has taken a stand against viewing of homosexuality as pathological. Although this is conjecture on Oordt's part as there are no data from a limited survey of this type to support his hypothesis about why so many indicated that they "don't know," it is an important issue. Rosik (2003b) also noted the difficulty in holding a religious value perspective on the issue of gay/lesbian change therapies and how the religious moral position is viewed as discrimination or homophobia. A nonsexual, dual role relationship is another area of discussion and concern among Christians, similar to the experience of secular therapists who practice in rural settings (McRay, McMinn, & Meek, 1998). Most professional codes proscribe 41 or, at least, discourage multiple-role relationships because of the potential for harm to clients. However, Christian therapists often practice in a church-based setting and are sometimes asked to counsel people with whom they attend church or socialize. A survey conducted by McRay et al. (1998) suggested that church-based counsellors were more likely to view multiple-role relationships as ethical and to have engaged in such behaviours. Another survey by McMinn and Meek (1996) showed a heightened tolerance among some unlicensed counsellors for multiple-role relationships. Unfortunately, due to the survey nature of these studies, there was no dialogue with the therapists about the context of these relationships, why they considered them ethical, and how Christian values may have influenced this behaviour. Richards and Bergin (1997) cited other areas of ethical concern for religious therapists. Therapists can displace or undermine the role of religious leaders by failing to collaborate with religious leaders or confusing the boundaries between the roles of therapist and religious leader. Second, therapists need to be aware of any policies regarding the use of religious interventions in their work setting so they do not violate any boundaries. For example, in a civic setting it is advisable before using an intervention such as praying with a client or reading Scripture during a therapy session, to discuss the suitability of doing this with supervisors and clients. Another ethical concern involves practising outside of the bounds of one's competence. A therapist who holds similar religious views as a client is not necessarily competent to introduce spiritual dimensions in therapy. Just as with 42 other diversity issues, adequate training is essential to ensure that benefit, not harm, results from the use of any spiritual interventions. There are no research studies that specifically address these issues, but Guinee (1999) addressed the role of a Christian therapist in a secular work setting. He says: "Christian therapists, like all Christians, are exhorted by The Great Commission (Matthew 28:19) to ...go and make disciples of all nations.... I propose that Christian therapists in secular settings are obligated to witness to their clients" (pp. 69-70). It would be interesting to pursue how other Christian therapists view this suggestion and whether or not they would identify this as an ethical dilemma. The whole area of therapist values is an important one, especially with the recognition that therapy is value-laden. Religious values are recognized as foundational for many people and there is a growing recognition of the importance of incorporating religion and spirituality into therapeutic practice. Professional associations require conformance to an ethical code and these professional values also greatly impact practice. A concern is raised when personal, religious values come into conflict with professional values and it has been noted that some Christian psychologists do experience tension between these conflicting values (e.g., Chapelle, 2000). However, there is a lack of research looking at the impact of these religious values on ethical practice. The purpose of this study was to explore how Christian psychologists deal with the tensions they experience between their religious values and the values of professional ethical practice. The question I asked was, "What factors help or hinder Christian psychologists in dealing with the tensions they experience between their 43 Christian moral values and the ethics of professional psychological practice as embodied in professional ethics codes?" The method used in the study provided participants with the opportunity to dialogue in an open-ended manner about the tensions they experience between their Christian ethics and professional ethics and how they resolve this dissonance. This will add a dimension to the research that is presently not available and will, hopefully, provide valuable information for other Christian psychologists and counsellors in understanding similar value tensions and incorporating religion into the therapeutic setting in an ethical manner. 44 Chapter 3 - Method The primary reason for selecting a qualitative methodology for a study investigating the resolution of value tensions experienced by Christian psychologists is to generate rich descriptions of the participants' experience from their own perspective. Denzin and Lincoln (2000) suggest that qualitative research "involves an interpretive, naturalistic approach to the world. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret phenomena in terms of the meanings people bring to them" (p. 3). This circumvents the limitation of survey research (which is the predominant format reported in the literature review in Chapter 2), in which the participants are presented with researcher-determined forced choices. By engaging in a dialogue with participants, stories were elicited about how their Christian values and professional values interact. This is consistent with Jones' (1994) recommendation that religion and psychology enter into a dialogical relationship, with each informing the other. Qualitative methodologies are also more consistent with my epistemological beliefs. Traditional scientific inquiry and quantitative methods are based on positivist, empiricist assumptions, which contend that reality can be studied, identified, and understood. In this tradition it is assumed that scientific knowledge is "grounded in empirical facts which are fixed and absolute in their meaning (Mahoney, 1991, p. 44). My beliefs are more in keeping with postpositivist views and some of the interpretive/constructivist sensibilities. Postpositivists believe that 45 reality cannot be fully known, only approximated through its representations (Denzin & Lincoln, 2000). I also believe, along with social constructionists, that we construct knowledge and reality based on interpretations filtered through lenses such as language and culture. However, I do not ascribe to the social constructionist idea that there are no essential truths. I do believe that there are some absolute, objective truths, yet I am not sure that we ever fully know or comprehend this reality. As Mahoney (1991) states, the knower, the knowing, and the known are inseparable. Denzin and Lincoln (2000) assert that we can never capture objective reality. I would not be so absolute as to say "never," but I do agree that the process of ascertaining reality is difficult. Qualitative researchers assert other ideas that are consistent with my views. These include recognition of the value-laden nature of scientific inquiry, an acknowledgment of the impact of the researcher on what is researched, openness to multiple methodological perspectives, and the awareness of situational constraints that shape the process of inquiry (Denzin & Lincoln, 2000). One of these situational constraints is understanding the sociocultural context of peoples' lives and the positioning of the researcher within this context. Morrow and Smith (2000) discuss the importance of immersing oneself in the research setting when conducting qualitative research to increase understanding. "Immersion in the setting enables the researcher to form relationships with participants, frame interview questions that are relevant and understandable, give background from which to view subsequent data, and add complexity to the understanding of the phenomenon" (Morrow & Smith, 2000, p. 209). 46 Researchers position themselves as "insiders" (part of the population to be studied) or "outsiders" (not part of the population). An insider position can enhance the immersion and subsequent understanding of the social context. This will likely generate increased acceptance, trust, and openness among participants, which often elicits better-quality data (Morrow & Smith, 2000). However, being an insider also makes it more likely that the researcher will take for granted shared meanings and assumptions and fail to delve deeply enough into participant meanings. I entered this research from an insider perspective and endeavoured to maintain awareness of the pitfalls of this position in order to limit any negative effects on the quality of data obtained. In choosing a method for this study, I wanted one that would answer a "what" question and would capture more than a description of the meaning of the tension participants feel between conflicting values (as would be the case in a phenomenological study). I wanted the participants to tell me what factors helped them in the process of resolving the tension between conflicting values. The Critical Incident Technique (CIT, Flanagan, 1954) is one method that satisfies these requirements. This method of data collection allowed me to dialogue with Christian therapists, giving them the opportunity to tell their own stories about ethical dilemmas they have encountered in practice. Within the structure and focus of CIT, participants were asked to discuss areas in which they experienced conflict between their religious values and those of professional ethical practice, and the resources and factors that enabled or hampered them in the process of resolving this tension. These stories were expected to elicit some of the areas discussed in 47 the literature review, but the method also permits discovery of issues that may not have been previously considered, and some of these will be reported as well. In this chapter, I will provide some background and history of CIT, review the method, describe the participants in the study and outline the interview process, analysis of data, and validation procedures. Design Critical Incident Technique The Critical Incident Technique (CIT) was developed by John Flanagan (1954) during World War II in order to identify criteria for effective pilot performance. Flanagan originally described CIT as ... a set of procedures for collecting direct observations of human behavior in such a way as to facilitate their potential usefulness in solving practical problems and developing broad psychological principles. The critical incident technique outlines procedures for collecting observed incidents having special significance and meeting systematically defined criteria (p. 327). Flanagan (1954) describes five steps in CIT: a) establishing the aim of the study, b) developing plans and specifications, c) collecting the data, d) analyzing for thematic categories derived from the data, and e) interpreting and reporting the findings. This is the general format that was used in this study. Part of the data analysis is to identify incidents that help or hinder a particular process. Flanagan (1954) says that, in this stage of identifying incidents, clear 48 instructions must be given about what constitutes a critical incident. By an incident is meant any observable human activity that is sufficiently complete in itself to permit inferences and predictions to be made about the person performing the act. To be critical, an incident must occur in a situation where the purpose or intent of the act seems fairly clear to the observer and where its consequences are sufficiently definite to leave little doubt concerning its effects (p. 327). Forming thematic categories is the core of the analysis process. Woolsey (1986) suggests that categories should be formed based on the frame of reference and intended use of the results. In this study, I hope the results will be of interest to educators of psychologists and counsellors and in developing the categories and I kept in mind the question "What insights might these categories offer to others dealing with similar tensions?" After the war, Flanagan further developed the technique and described its use for research in industry to identify occupational competencies and to conduct personnel screening. The method was eventually expanded and applied to other areas of research involving psychological constructs. Herzberg, Mausner, and Snyderman (1959) conducted a study to identify the factors that affect work motivation. Flanagan (1978) used CIT to research quality of life in America. Wong (2000) notes that, in this latter study, CIT evolved to include phenomenological experiences. In this expanded version of CIT, critical incidents can be conceptualized as subjective experiences, feelings, beliefs, attitudes, and traits, as well as behaviours. 49 Andersson and Nilsson (1964) concluded that the CIT is both reliable and valid in providing a detailed and comprehensive depiction of a content domain. CIT has been used to study a wide variety of psychological domains including relationships (Woolsey, 1986), work motivation (Herzberg, Manseur, & Snyderman, 1959), psychological aspects of nursing (Rimon, 1979), group processes (Cohen & Smith, 1976), and the evaluation of the clinical practicum setting (Dachelet, Wemett, Garling, Craig-Kuhn, Kent, & Kitzman, 1981). This flexibility makes CIT an ideal method for studying a wide range of phenomenon in psychological research. To date, CIT has been used extensively in Counselling Psychology research studies, including several conducted at the University of British Columbia: McCormick (1994) looked at the factors that facilitate healing in first nations people; Ross (1997) collected critical incidents regarding factors that helped and hindered personal agency in employment groups; Alfonso (1997) studied factors that helped to overcome depressed moods after an HIV+ diagnosis; Logan (2001) looked at factors that helped and hindered successful hostage negotiation; Baum (1999) identified successful coping strategies for victims of the Holocaust; Borgen and Amundsen (1984) studied the experience of unemployment; and Woolsey (1986) used CIT to identify the characteristics of same-sex social bonds. The flexibility of this method also makes it very fitting for this study in which participants are asked to articulate a wide variety of factors that help or hinder the resolution of tensions. 50 Researcher's Role Flanagan noted that CIT does not consist of a rigid set of rules, but rather "it should be thought of as a flexible set of principles which must be modified and adapted to meet the specific situation at hand" (1954, p. 335). The role of the researcher has been modified in this study from Flanagan's original description. Although CIT traditionally adopts the stance of researcher as objective observer, I wanted to account for the joint construction of meaning inherent in the dialogue as I engaged in the interviews and analysis of the data. Mishler (1986) describes an interview as a dialogical process in which meaning is jointly constructed. Respondents interpret the meaning of questions as the interviewer responds to their answers. Respondents tune into the verbal and nonverbal cues presented by the interviewer and this significantly impacts the ongoing process of responding. I concur with Mishler's position that the interviewer is not an objective observer; rather he/she is integral to the dialogue process and the information obtained is not independent of the researcher's influence. Mishler (1986) then points out the power dynamics inherent in the process: In a standard interview respondents are presented with a predetermined scheme of relevances: topics, definitions of events, categories for response and evaluation are all introduced, framed, and specified by interviewers, who determine the adequacy and appropriateness of responses...This way of doing research takes away from respondents their right to 'name' their world (p. 122). There is a marked power differential between interviewer and participant, with the 51 most power residing with the interviewer. A goal of more open-ended interviewing is to reduce this asymmetry of power by restructuring the interviewer-interviewee relationship so that the participant is empowered to speak in his/her own voice. Mishler (1986) advocates a more empowering way to structure research interviews: Yielding control to interviewees of the flow and content of the interview, entering into a collaborative relationship, attending to what and how interviewees may learn from their efforts to respond meaningfully to questions within the context of their own worlds of experience, giving them a voice in the interpretation and use of findings, serving as advocates of their interests - all these "research methods" radically alter the standard definition of a researcher's role and aims (p. 131). The integrity of a study can be markedly influenced by the fact that researchers bring their own biases, assumptions, and theoretical predispositions into the process (Ahern, 1999; Kidder & Fine, 1997; McLeod, 1996). Reflexivity is a process of critical self-reflection to explicate and articulate these biases and to understand how they impact on the research process (Schwant, 1997). One way of promoting reflexivity is to maintain a journal to explore issues pertinent to the development of a reflexive attitude (Ahem, 1999). I maintained such a journal throughout the research process, trying to answer a number of questions to guide my personal reflection: What are my assumptions? What am I taking for granted here? What do I expect to find? Why does this resonate with me? Why does this make me uncomfortable? How might this be different for another group of 52 participants? How might this be different if I were different (older/non-white/male/non-religious)? How does this phenomenon work? What are its rules? What language is being used and what does that say? A second means of promoting reflexivity is to dialogue with others. Meeting with my research committee members opened up areas for self-reflection. I spoke with other qualitative researchers and had the opportunity to talk about my research and receive critical feedback. It was especially helpful to dialogue with people who hold different values and beliefs from either my own or the participants I interviewed. I was challenged to articulate the worldview in which I operate and from this I was able to recognize some of my biases and insider perspective and language. Third, is the reading of critical texts about research and the research process. I read articles and texts that provide a critical analysis of research and of self in the research process. This reading fostered ideas for both the journal and dialogue endeavours. Through this kind of reflexive journaling, dialoguing, and reading, I am able report more clearly about how I interact with the research and how this impacts the process and the findings. A discussion of my perspective can be found in Chapter 1 and further notes on this reflexive process can be found at the end of Chapter 5. Establishing the Aim of the Study Clarifying the aim for this study was, as Woolsey (1986) suggests, one of the most difficult tasks for me, and it required much thinking and refining to focus the 53 research question. In this process, I consulted the literature to gain an understanding of the issues involved in considering value tension. I then spoke to professors and peers in an effort to articulate what I wanted to do. Often, I was directed back to the literature to gather more information. In some of my course work I wrote papers on topics related to this interest in value tension, and I received valuable feedback from instructors. In one course, I had the opportunity to conduct two interviews with Christian counsellors, and I developed a prototype of the interviews I planned to conduct in this study. This interview experience and the feedback from the professor were invaluable in understanding more fully a qualitative research process and my position as researcher. This ongoing process of talking, writing, and getting feedback allowed me to clarify my thinking and develop the research question that describes the aim of my project. Participants Determining criteria for selecting participants is part of the step Flanagan called "developing plans and specifications." This section will describe the criteria used to select participants and characteristics of those participating in this study. I recruited according to the following inclusion criteria: the participants must 1) be registered psychologists, either in a Canadian province or American state; 2) fit the description of an "evangelical" Christian by stating their agreement with the Statement of Faith of the Christian Association for Psychological Studies (CAPS): 54 Belief in God the Father, who creates and sustains us; Jesus Christ, the Son, who redeems and rules us; and the Holy Spirit, who guides us personally through God's inspired Word, the Bible, our infallible guide of faith and conduct, and through the communion of Christians. 3) have a willingness to conduct an initial audio-recorded interview of 60 - 90 minutes and a follow-up interview to review the findings for accuracy; 4) have the ability to articulate, in English, a time when he/she felt a tension between Christian moral values and professional values. Twelve participants fit the criteria for the study and demographics of these participants are described in Table 1. 55 Table 1 Demographic Information of 12 Participants Variable Description Average Age Gender Country of residence Education Years experience Work setting Ethics training Primary ethics code Religious affiliation 47 years (range 39 - 66) 8 male; 4 female 6 Canada; 6 US 11 PhD or PsyD; 1 MA; 5 obtained graduate training in psychology from a Christian university; 3 also hold a divinity or theology degree 16.4 years (range 8 - 3 0 ) 7 work in urban setting; 5 in suburban; 7 work in primarily Christian setting; 5 primarily secular range of settings included private practice, pastoral care, university, military, hospital 3 described themselves as primarily academics 9 did graduate course work in ethics; 7 require ongoing C E U s for licensing; others noted licensing exam, reading, theology education or none 5 APA; 2 C P A ; 3 Provincial; 2 State 4 Baptist; 1 Mennonite; 1 Assemblies of God; 1 Pentecostal; 1 Roman Catholic; 1 Episcopalian 2 Non or inter-denominational; 1 Mixed 56 Another aspect that describes the participants was their orientation to the relationship between psychology and Christianity. At the close of each interview, the participants were asked to consider the four positions regarding this relationship as outlined by Kirwan (1984), and relate which one would best describe their beliefs. The four choices Kirwan suggests are: a) un-Christian view - human reason is the ultimate source of truth and religion has nothing to offer; b) spiritualized view - all emotional disturbances are spiritual problems; c) parallel view - little overlap between Christianity and psychology; and d) integrated view - truths of psychology and the Bible can be integrated in a harmonious fashion. All participants answered "d" (an integrated view) as the choice that best fit their beliefs. One person noted that "c" was somewhat true as well, and another person that in some cases, they believed "b" as well as "d." Procedures Recruitment of Participants I sent approximately 50 letters (Appendix A) outlining the aim of the study and an invitation to participate to psychologists with whom I had made contact, any who had been referred to me, and others from the C A P S membership list who lived either geographically close (in either Canada or the US) or in areas I was planning to visit. From these letters, fifteen people agreed to participate in the study. I prevented the potential for dual relationships by excluding any psychologist with 57 whom I have had a pre-existing relationship. Sample size with CIT is based on the number of incidents rather than the number of participants. The general rule is to interview participants until a saturation level for new incidents is found (Alfonso, 1997). I had reached saturation after the first nine interviews, indicating that the sample size was adequate. Of the fifteen people interviewed, data from twelve of these interviews (Group A) was used in the final analysis. Three of those agreeing to participate did not fit the criteria for the study (Group B). These three participants stated at the beginning of the interview that they did not experience any tensions between their Christian moral values and values of professional practice. I decided to complete the interviews on the chance that an experience of tension would emerge and I adjusted the questions to explore why these participants did not experience tension. It was decided that these three did not fit the criteria for participants and the data was not included in the critical incident analysis. However, a separate analysis was done of these participants and interviews and is included in Appendix K. There do not appear to be any systematic differences between Group A and Group B participants. The demographics for Group B are reported in Appendix J . Interviews Data was collected through semi-structured interviews. All interviews took place between April and November, 2001.1 interviewed a total of 15 psychologists for the study, 8 in Canada and 7 in the US. I interviewed 7 people in B.C. by going 58 to their offices or homes. On a trip to eastern Canada in the fall of 2001, I interviewed one psychologist. I attended a C A P S West convention in San Diego, C A in June, 2001 and was able to conduct 4 interviews in the conference hotel. I traveled to Washington State to interview three psychologists at their offices. As mentioned above, only 12 of the 15 psychologists interviewed fit the criteria for selection. At the beginning of each interview, I reviewed with participants the aim of the study and clarified the nature of the events to be reported. The participants were presented with a consent form that outlined the purpose of the study, the types of questions to be asked, assurances of confidentiality, and their choice to withdraw at any time (Appendix B). Both participant and researcher signed this form and each participant was given a copy of the signed consent form (see Appendix B). I then gathered some relevant demographic information (Appendix C). Participants were then asked to identify a time when they experienced tension between their religious, moral values and the values of their professional ethics codes or standards of practice. Clarifying questions were used to help in depicting these tensions. When these tension-generating situations were identified, participants were asked to describe any events or factors that helped them or hindered them in the process of trying to resolve the tension. It was not necessary that the tension be fully resolved, rather the focus was on the process. The time frame for these incidents was not restricted. Flanagan (1954) suggests that the more recent the report of retrospective data, the better, in terms of accuracy. However, some of the tensions were long standing and I wanted to collect all of the 59 incidents that participants could recall that impacted on the resolution process. The following interview questions were used: "Think back to a time when you felt tension between your Christian moral values and the values that are embraced by your professional psychological association (usually via the association's code of ethics). • Describe the situation including the experience of the tension and the difficult choices perceived. • What Christian value was at stake here? • What professional value was involved? • What events or factors help/helped you in the process of working toward resolution of this tension? • How does/did it help? • What events or factors hinder/hindered this process? • How does/did it hinder? • What other things helped or hindered in this situation? • Are there any other situations in which you experienced tension between personal and professional values?" The interviews were audio taped to preserve accuracy and to make the information more retrievable (Rubin & Rubin, 1995) and transcribed verbatim either by a hired transcriber or myself. Each participant was given a number code (between 1 and 15) to protect his or her identity. After each interview, I wrote some notes about the process including my perceptions of and reactions to the 60 participants as a way of discerning the issue of potential bias. Analysis of Data I listened to each audiotape several times to familiarize myself with the information and also to check for accuracy in the transcripts. I wrote any comments taken from the interview notes on the transcripts to provide additional information that helped in capturing a fuller understanding of the meaning of the texts. Each transcript was read once along with the audiotape to check for accuracy and then twice more to gain a sense of the full meaning of the statements. The first stage of the analysis required the identification of the tensions the participants experienced between their religious values and values of professional practice. This involved asking the participants to relate situations in which they experienced some tension and then to identify the Christian and professional values that were in conflict. These tensions were given descriptive names (e.g., abortion, divorce, homosexual behaviour, dual roles, dealing with spiritual issues). The tensions were then grouped according to similar subject matter. This process was done using a word processing program in which sections of text were cut and pasted into a "tensions" file for each participant. These tension files were then moved into a software analysis program, ATLAS.ti® to facilitate the grouping into subject areas. The tensions identified and examples from the text are reported at the beginning of the Results chapter. The next step was to identify incidents that helped or hindered the process of resolving these tensions. The incidents were reviewed to ensure that they fit the 61 following decision rules for what constitutes a critical incident: (a) Was the participant's account stated in a complete way? (did the event come out of a description of a particular situation in which the participant experiences some tension between Christian values and values of professional ethical practice?) (b) Was the event clearly identified? (what was helpful or hindering to resolving tension?) (c) Was the outcome related to the purpose of the study? (dealing with tension). The process of identifying helping and hindering incidents was done using a word processing program. From the transcript, for each participant, original text was cut and pasted into either a file labelled "helps" or one labelled "hinders." At the end of this process I had two files for each participant, one that included the actual text of the incidents that helped in dealing with the tension and another that included the text of incidents that hindered the process of dealing with tension. A qualitative analysis software program, ATLAS.ti® was used to analyze the helps and hinders files. After each participant's helping and hindering incidents were identified, these files were assigned to larger files in ATLAS.ti® designated as "Factors that Help" and "Factors that Hinder." These were the files that required further analysis, including coding and categorization. As each participant file was moved into ATLAS.ti®, the incidents were coded using a name that captured the meaning of the text (e.g., client feedback, family support, self-examination, a sense of purpose/calling, ethics course, supervisor, 62 theology training, fear of other's perceptions, lack of role model). The incidents from these files were then grouped into categories according to similar content and meaning. This began the inductive process of forming and reforming the categories, as this grouping was repeated several times throughout the analysis. The first grouping was done after reviewing the first four transcripts, creating a preliminary categorization. These categories were given names. At this point there was a total of 99 incidents that were placed into 11 "helps" categories and 6 "hinders" categories. This categorization process was repeated after 8 transcripts were coded. At this time there were 193 incidents. Some of the categories were renamed or reformed, resulting in 12 helping and 6 hindering categories. The third categorization included 11 of the 12 transcripts. There were a total of 280 incidents that were placed into 13 helping categories and 5 hindering categories. Although incidents were identified in the 12 t h transcript, these incidents were not added to the categories until later, as a validation check for the categories. The categories continued to evolve as each incident and category was thoroughly examined and changes made. These changes involved recoding some incidents, omitting others because it was decided upon careful reflection that they did not meet the decision rules for inclusion (listed above), and reforming the categories based on input from the research committee members and people helping with validation procedures. After the categorization and validation procedures were completed, 306 incidents were identified and placed into 13 "helps" categories and 5 "hinders" categories. These categories are described in the 63 Results chapter. Analysis of Group B Participants The second group of participants (Group B), those three that did not fit the initial criteria, was analyzed separately and in a less formal manner. The transcripts were read over several times to facilitate understanding of the essences of their reports. A summary of the interview, including direct quotes, was prepared for each of these participants. The focus of this synopsis was on why they did not experience the tension the other 12 participants described. This summary was sent to each participant for feedback to ensure that the report was accurate and included all of the important points. These findings are reported in Appendix K. Establishing Validity and Trustworthiness Validity, or, as qualitative researchers often designate it, trustworthiness, answers questions about the soundness and believability of the research results. Anderson and Nilsson (1964), using several different methods to test the validity of the category system and the reliability of the method, concluded that the information collected using the critical incident method is both valid and reliable. Maxwell (1992) describes three types of validity common in qualitative research: descriptive validity, interpretive validity, and theoretical validity. 64 Descriptive validity deals with the factual accuracy of the account. In this study, the interviews were tape recorded and transcribed to ensure accuracy of participants' words. Unclear descriptions were marked and clarified. A second contact with participants was very valuable in this regard as it gave participants the opportunity to read through the transcript excerpts and make any corrections in wording or meaning, thus avoiding distortion of the participants' accounts. Interpretive validity refers to the meaning that participants give to events and behaviours, thus taking into account the participants' "voice." "Interpretive accounts are grounded in the language of the people studied and rely as much as possible on their own words and concepts" (Maxwell, 1992, p.289). Questions asked during the initial interview and feedback solicited during the second phone or email contact sought to obtain a clear understanding of the critical events. Participants were also encouraged to comment on the category structure to ensure these categories encompassed the intended meaning of the critical incidents. Theoretical validity is concerned with the legitimacy within the research community of the application of the terms used to characterize a phenomenon. The use of expert raters and comparing the findings with relevant literature are two ways to establish theoretical validity. Following is a summary of each of the validation procedures used in this study, including those mentioned above. The results of the validation process will be reported in the next chapter. To ensure that the data gathering process was effective, a pilot interview was conducted. This interview was transcribed and analysed. It was then shared with 65 committee members for feedback and suggestions for revisions. This interview was considered consistent with the overall aims and method of the study and was included in the overall analysis. To test the consistency of the critical incidents established by the researcher, an independent extraction of the critical incidents was undertaken. An independent rater read three of the transcripts and highlighted the helpful and hindering incidents. This rater was a graduate of the Counselling Psychology Masters program at UBC and very familiar with the Critical Incident Technique. Percentage agreement was calculated between the incidents she identified and those I identified and we discussed the discrepant incidents. The categories formed in CIT must be judged for their comprehensiveness, consistency of use, and soundness. Several procedures utilised in previous studies were used to establish the validity of the categories extracted from the interview data (Alfonso, 1997; Andersson & Nilsson, 1964; Butterfield, 2001; Flanagan, 1954; Maxwell, 1992; Wong, 2000). The first method is to conduct a second consultation with participants. The purpose of this contact was to have participants review the description of the incidents for accuracy, to check the categories for relevance, and to have the opportunity to provide additional incidents. This is consistent with the epistemological view that the interpretation of phenomena in qualitative research is jointly constructed. I contacted each participant by email or phone to check whether they were willing to carry out this validation procedure; all agreed. I sent each person a letter (either by e-mail or regular mail) explaining the process (Appendix H), a file delineating the tensions he/she had described, and a 66 file reporting the helps and hinders categories with each participant's specific incidents reported in each of these categories. Each participant was asked to read through the document labelled "Tensions" and ensure that I had captured the essence of what they had described. They were then asked to read through the document labelled "Helps and Hinders" in which each person was given a description of all the categories and their own helps and hinders incidents were listed under the appropriate category. They were asked to check for accuracy in the quotes and to add anything to the quote to explain it further. They were then asked to provide feedback on the appropriateness of the code name in capturing the essence of the meaning for each quote. Participants were asked to contact me regarding any questions or points to clarify. They were asked to respond by email, phone, fax, or in person if living within close geographical range. Most participants answered by e-mail, two by regular mail, and two by in-person contacts. Second, the consistency of the categories was checked using two independent raters. The first rater was a graduate of the Counselling Psychology Doctoral program at UBC and second was a student in the same program. Both were familiar with CIT. Each rater was provided with a brief description of the categories and then asked to sort a sample of incidents into the defined categories (Alfonso, 1997; Anderson & Nilsson, 1964; McCormick, 1994). The percentage agreement between the rater's classification of incidents and my own was then calculated. Anderson and Nilsson (1964) suggest that an agreement level of 75 -85% is adequate to establish reliability. The discrepant incidents were discussed to 67 try and come to a consensus regarding their category placement. A third method to check the exhaustiveness of the categories was to hold back about 10% of the critical incidents until the categories had been formed. This was done by not including the 30 incidents from the twelfth transcript in the category formation process. These remaining incidents were then examined to see if they fit into the existing categories (Andersson & Nilsson, 1964). In this process, if some incidents do not fit, then the completeness of the category system would be under question and revisions would have to be made. Fourth, participation rate was calculated by adding the number of participants who endorsed each category and calculating the percentage of participation. Flanagan (1954) suggests that the higher the participation rate, the more valid the category. Borgen and Amundson (1984) suggested that a 25% participation rate is sufficient to establish validity of the category. A fifth method to test for soundness involves expert validation. Experts in the subject field were solicited to comment on the relevance and usefulness of the categories for facilitating or hindering the process of resolving value tensions. Two psychologists, one from British Columbia and one from Washington State, both working as educators and practitioners in the field of Christian counselling and ethics, agreed to be expert validators. These contacts were made by e-mail, consistent with Alfonso (1997), who noted the benefit of the internet in reaching experts from around the world. Lastly, content validity or soundness of the categories was assessed by comparing the findings with relevant literature (Flanagan, 1954). If categories or 68 events agree with previous literature, there is evidence to support the soundness; if categories and research disagree, questions would be raised regarding the trustworthiness of the findings. The results of these validation procedures are reported in the Results chapter. 69 Chapter IV - Results Fifteen psychologists from Canada and the United States who identified themselves as evangelical Christians participated in this study. Only 12 of these people fit the criteria for inclusion and these 12 were included in the final analysis. The other three participants reported that they did not experience tension between their Christian moral values and professional ethical values and the transcripts for these three participants were analyzed separately. From interviews with 12 psychologists, a total of 306 critical incidents were identified and categories or themes developed. Critical incidents that helped in the process of dealing with value tensions were represented in 13 categories and incidents that hindered the process were classified into 5 categories. In this chapter I will begin by describing the tensions that the participants reported in order to provide some background and context for fully understanding the factors that helped and hindered these psychologists in working through moral tensions. I will then present the categories with a brief description of each and examples of incidents that comprise the category. A report of the methods used to establish the validity of the categories is also presented. Tensions The purpose of this study is to determine what factors help or hinder Christian psychologists in dealing with tensions between religious values and 70 values of professional ethical practice. The first step in the research was to delineate the tensions described by participants. Each participant defined the substance of these tensions for her or himself. I started each interview by asking the participants to describe a time when they experienced tension between their Christian moral values and values of professional practice. Each person remembered situations in which they were faced with a conflict between their commitment to live out their Christian faith and the demands of a more "worldly" point of view. The tensions were identified in each transcript and then combined by grouping them into categories that had similar content. These categories covered variety of subjects and will be reported under the following headings: Being a Psychologist; Integrating Religious Beliefs and Practice; Clients with Conflicting Values; Dual Relationships; Other Tensions. In describing the tensions, most psychologists expressed a sense of "not knowing" - what to do, or what to think, < how to respond when these situations presented themselves. For some there seemed to be a specific moment in time in which the tension appeared and was dealt with. For others it was an ongoing process, which may or may not be resolved. The specific tensions will be described using quotes from the transcripts. Each participant has been given a number rather than a name to protect their identity. 71 Being a Psychologist Three of the participants described a great deal of conflict in their decisions to study psychology and enter the profession or, later, to continue working in this field. This stemmed from the realization that psychology was founded on a worldview much different from, and sometimes oppositional to, their Christian beliefs. #4 I had a terrible time with psychology versus Christianity.... Well the most fundamental tension was that the psychology I was learning was devoid of a Creator. It was devoid of a Christian worldview. It was naturalism. #12 I would say I have always felt some tensions even when considering this profession and it was a very difficult, long process of deciding to become a psychologist because of my awareness of different practices and ideas in psychology that seem to be hostile to, or in opposition to Christian faith... For example, there was a lot that seemed to be suggesting a determinism about what it is to be human... and a sense of kind of narrowly defining what it is to be human. 72 #1 I was reflecting on the fundamental Christian sense that Christ is sufficient to produce change in people's lives and why I was in this field of psychology... I think that the main tension is whether it's okay to just help people live better lives without them developing a sense of their dependency on God for their well being, not just eternal well being but present well being. And psychology seems to be about helping people to figure that out on their own without necessarily drawing their attention to God, and we must have a relationship with God in order to be okay.... One says, that you have within yourself what's necessary to have a good life, and the other, the Christian value says no, that's not the case. Integrating Religious Beliefs and Practice Some participants spoke of their discomfort at trying to integrate their Christian beliefs into their psychological practice. Psychology was seen as condoning, even promoting what some considered immoral practices or even sinful behaviour. Tension was noted when the psychologist was faced with client issues that were seen as stemming from spiritual roots or including spiritual concerns. These included such things as searching for meaning and purpose in life, considering demon possession in the differential diagnosis, and not knowing how to address spiritual issues in an ethical manner with a client who was suicidal or dying. 73 #9 What I was hearing in therapy was what I would call a relativistic philosophy, which is like there's no such thing as right or wrong, whatever feels good - do it sort of. That's basically relativism... I got the impression that that was what psychology was founded on which sort of meant that everything is equally good or equally bad.... And I think Christian teachings are not that way. #6 So how do you deal with sin in a valueless way with an ethical code that says keep your values out of it and it's a mental health issue and not a sin issue? #1 With clients, on occasion, where I see what seems to be largely a spiritual issue, somebody searching for a sense of worth or identity ... do I say more directly from what I believe about the need for a personal relationship with God or do I hold back on that? #5 I believe in the supernatural, and I believe in the existence of demons. And I believe that that could be diagnostically a factor. And that is not at all believed in secular [psychology]... and that therefore the 74 treatment of choice would be something addressing what I believe to be a reality. #12 When I work with people who are Christians they will bring something up about potentially spiritual issues involved.... And so I don't feel uncomfortable relating the whole issue of the choice to take your life to one of the spiritual aspects of that and bringing God into the picture... and when I face situations with people who aren't Christians I really do feel like I'm grasping, and I don't know exactly how to proceed in a way that would feel like my profession would endorse it. Clients with Conflicting Values Common tensions among the participants involved working with clients who were engaged in specific behaviours that demonstrated conflicting values with those of the psychologist. These included working with gay/lesbian individuals or couples, and clients contemplating divorce, extra-marital sexual relations, and abortion. The Christian values of these participants proscribe these behaviours and yet the professional ethics codes maintain that psychologists not engage in any discriminatory behaviour. 75 #8 And so my view is that homosexual behaviour is not desired by God, not approved of by God. It's something other than what God intended. #6 One that's come up a couple of times has been in marital therapy where I either had a couple or a single individual that was contemplating divorce and really was looking for me to say that "yeah, it's okay, go ahead and do that" and that created a 'moral' slash 'ethical' dilemma for me. #4 He wanted me to help him with his sexual performance and he wasn't married.... I thought what he was doing was wrong. It was pre-marital sex, which is essentially Biblically wrong, but mostly I felt sullied by the thought of trying to help him with this behaviour. That was my reaction to it... to me it's not healthy, wholesome behaviour. #10 And the same with abortion that it was such a value laden decision.... life is sacred and that it's a sin and you don't talk about sin. And so it makes it difficult sometimes to know when do you say that and when do you not. 76 Dual Relationships Another issue that was meaningful for some was how to handle dual relationships. Christian community is somewhat like a small town or rural area where it is not uncommon for therapists to see their clients in other settings besides the therapy office. Several psychologists talked about their struggle with this issue in which they wondered how to maintain professional boundaries and yet live out their religious understanding of loving others and Christian community. #1 Yeah, I admit, there's some awkwardness around that latter issue [dual relationships] 'cause some of the people I see wind up going to my church and how much do I socialize with them? [The Christian values is] I guess the idea of being loving and accepting of people and also of being one's self with people [versus the professional value that] it's this idea of keeping this professional separate boundary and you only interact with somebody in the context of the therapy hour. #8 There are a number of interesting definitions of dual roles and [at] one of the more recent ethics updates I went to the presenter, who was a reviewer for the [ethics] board, basically said unless you're in a very rural area, you should never see a member of your church, civic organization, etc, etc, etc. because if they're a member of anything 77 you're a member of that, by definition, is a dual role. And I know I have a little bit more narrow definition of a dual role and that is if that person is a friend of mine, if they're in my Sunday school class, well yes, of course, I would not see them because there's a dual role. And I think there is in a sense a commitment on the part of me as a Christian therapist to provide support to the body of Christ.... But I think that if in fact the professional association is choosing to define dual roles [this way] that does violate, I think, some of our basic call to community. Other Tensions Two other issues that were mentioned as tensions were financial reimbursement and spanking children. The issue about finances involved putting a priority on care of people versus care of self and profession. Spanking children is an accepted way to discipline children in some Christian circles. The psychologist who raised this issue did not agree with this stance. #1 One other area has to do with payment for services. That actually can be a big one 'cause as a Christian, I'm thinking what's important is that people get well. As a professional, I have a vested interest in upholding the interests of all professionals like myself. Not giving 78 away service because that dilutes, makes it difficult for other counsellors. As well as needing to maintain an income and feeling like my worth is partly dependent on how well I do financially. So it's a way of measuring success. So, there is that tension - how much of my time do I give away, how nit-picky am I about details on my billings? #10 I personally don't think we should be spanking kids and when I hear some very dogmatic statements around spanking from either Christian or non-Christian families, to me that's very offensive.... So the challenge in working with Christian families is how to get that across because they'll just regurgitate [well-known Christian writer/speaker] or "spare the rod, spoil the child" kind of nonsense, which just irritates me. And so how do you work with that? Description of the categories Recounting these tensions sets the stage for participants' reports of what helped or hindered them in working toward some resolution. Analysis of transcripts identified 255 critical incidents that helped in the process of tension resolution and 51 incidents that hindered this process. These were grouped into 13 helping 79 categories and 5 hindering categories. Table 2 lists the helping and hindering categories, shows the frequency of incidents in each category and the participation rate. The participation rate is discussed in the validation procedures later in this chapter. 80 Table 2 Helping and Hindering Categories Help ing Category F r e q u e n c y 3 Part ic ipat ion ra te b Experiencing Direct Support 43 100% Following God's Teaching/Open to God 29 100% Formulating Beliefs & Commitments 22 100% Acquiring Knowledge and Training 36 83% Engaging in a Process of Self Reflection/Growth 33 83% Clarifying Goals and Roles 22 83% Promoting Client Choice 12 58% Using Self-disclosure to Facilitate Client Empowerment 11 58% Managing Amount of Engagement 11 58% Engaging in Spiritual Disciplines 15 50% Possessing Personal Qualities 7 50% Accepting and Seeking Out Challenges 9 42% Accepting People 5 42% Hinder ing category My Own Disruptive Reactions 16 83% Antagonistic Beliefs and Biases 13 50% Lack of Understanding and Support From Others 14 42% Not Knowing 6 42% Legal Concerns 2 17% T O T A L 306 Note, n = 12. Frequency = number of incidents reported. "Participation rate = number of participants providing incidents under these categories. 81 The helping categories are presented below, followed by the hindering categories. In each of these sections, the categories are described in order of participation rate from greatest to least. Direct quotes from participants are used to illustrate incidents in each category. In cases where many participants spoke about a particular issue and there are many incidents in a category, I tried to limit the number of examples to four or five for that category. In other categories there were fewer incidents and this is reflected in my using fewer examples. In the categorization process, there was some overlap in the participants' quotes in that one quote sometimes described more than one incident. In reporting the results, I have limited the use a particular quote to only one category. Each participant has been given a number rather than a name to protect his or her identity. Helping categories Participants described factors that helped them to resolve tensions between their personal moral values and values of professional practice. The 255 incidents were grouped into 13 categories: experiencing direct support, following God's teaching/being open to God, formulating beliefs and commitments, acquiring knowledge and training, engaging in a process of self-reflection or growth, clarifying goals and roles, promoting client choice and responsibility, using self-disclosure to facilitate client empowerment, managing amount of engagement, engaging in spiritual disciplines, possessing personal qualities, accepting and seeking out challenges, and accepting people. 82 Experiencing direct support This category contained 43 incidents and includes experiences in which participants described some form or source of personal support, either direct or indirect. This support helped by giving them an opportunity to talk about the conflicts they were experiencing, and also gave them a sense that they were not alone in the struggle. Several participants mentioned having a supervisor who was open to their religious beliefs and was able to help them work through the tension. For others, consulting with peers offered input and advice into the dilemmas they were experiencing. Some discussed the importance of talking with other Christians who shared the same religious values. There was the sense that other Christians really understood and often shared the tensions and that they were not alone in the struggle. This provided freedom to explore issues that they sometimes did not experience with non-Christians. One participant also noted that many churches are now more accepting of psychologists, providing a greater openness to dialogue and feel validated that psychology has something to contribute to the Christian community. A feeling of support was generated more indirectly when participants noted that it is now legitimate to discuss religious or spiritual issues, whereas, previously, this was not looked on favourably in the profession. It was pointed out that professional ethics codes now sanction the inclusion of religious values and issues in the therapeutic setting and this led to greater freedom to talk about spiritual concerns both within the profession and with clients. 83 #12 One of the things that's helpful generally speaking, whenever I have ethical or clinical questions is I do consult with other faculty members. #1 Talking to other Christians, or other psychologists. I guess there's a sense of I'm not alone... The sense that I came away with is that it's okay to do things, to question things, to do things that are different from what maybe some other [secular] groups think is appropriate...so there have been some people that have led the way, I guess you could say. #10 So I think I've been fortunate probably in the last couple of years cause I've had more people to talk to and really wrestle with... and know that you're talking about Christian spirituality and we're not talking about anything else and that we're clear... And to have an understanding of the same experiences around what's it like to be spiritually alienated and what's it like to struggle and to suffer and still be a Christian and some of those kinds of things have been very worthwhile. So that's been helpful to have that. 84 #2 I know I struggled with that and I know I've probably talked about that with my supervisor who is not a Christian. After I expressed my views [and] my values... with my supervisor, I think it helped so that I don't feel like I'm being hypocritical in helping them [homosexuals] and yet holding these values behind. #6 One of the things that has changed in the, really in the last five or six years, is there has been a real resurgence of interest in including the spiritual in the therapy in psychology... and that has created a lot more opportunity and freedom to explore these areas with clients without so much fear and trepidation. Most of that is not coming from necessarily an evangelical Christian perspective, but it's opened the door to investigating this with clients... and actually the A P A ethical code states that that's one of the aspects of diversity that we're supposed to be dealing with adequately. It's listed there right along with sex, gender, race, colour and everything else. Following God's teaching/open to God There were 29 incidents in this category, which was characterized by all participants being open to God's teaching and/or leading and considering that openness as central to handling the tensions effectively. Participants spoke of 85 foundational beliefs about God being in control in their lives. Some spoke of the belief that God was guiding and directing their lives, and that they needed to look to this spiritual source for wisdom and understanding to figure things out. A major influence for some of the participants was the sense that God had called them to this profession and they saw working in this area as a divine calling. This gave them a sense of purpose and perhaps a sense of security that the tensions were not insurmountable and that God would provide answers. A source of answers for many was the Bible. Others mentioned that they were strongly influenced by Christ's modelling - since Christ demonstrated love and acceptance for people, so should they. Christian values, such as love and commitment, and God's ultimate authority were cited as fundamental issues that gave direction to some when values seemed to be in conflict. Several participants expressed the belief that God either created or allowed them to be in a situation that exposed them to and required them to struggle with a particular tension. They saw this as positive because it led to greater understanding and compassion for people. #12 It is a call and maybe it's also in some ways, if I think about it in terms of ultimate purposes then it's an honour.... to have been called, really to anything.... but called to this.... I've always felt, despite all the conflict that I've had, a sense of calling, that this is what God wanted. I felt it from the time I was 15 years old. 86 #10 I think.... looking at how Jesus, I think, treated everybody and how he treated everybody with love and kindness and compassion and there wasn't any hierarchy ... I think really helped in that setting. #2 I see it as God kind of throwing me into the midst of all these values' struggles that I've had.... that really that God was exposing me to these issues and really wanting me to confront them. #6 Probably the thing that prodded me to begin getting past the tension, was my eventual conviction that there was going to come a day when I was going to stand before God, and the question was not going to be, did you adhere to the A P A ethical code? Well, I really think it's going to be, "when this person came to you and they had a need and My Word [Bible] responds to it, or addresses it, did you talk about it with them, and did you help them find Me and did you help them live a life that was according to My moral precepts?".. . What seemed initially to be overriding this other thing that was telling me to do something different, and just say well, if I get thrown out of A P A for this, so be it. And I wasn't cavalier about it, I was still very careful and still very cautious and still very respectful and didn't try and impose 87 anything on anybody else, but it created enough space and freedom for me to start experimenting. #8 I think because my Christian value of commitment to people, and sort of that sense that we are called in so many ways in Scripture to bring help to each other... and to me that's just part of it and that doesn't mean that I can throw away the concept of dual roles. I still need to take that seriously. But I think there's a higher calling for us to be of support. Formulating beliefs and commitments This category, which contained 22 incidents, spoke about knowing (that is stating and understanding) one's beliefs and values and having the ability to articulate these clearly when confronted with tensions. This clarity provided a sense of grounding and a greater sense of security in knowing what to do and less likelihood that other's opinions or judgments would create imbalance. Some participants spoke generally about the importance of having achieved clarity in their beliefs in resolving tensions. They mentioned the effects of this clarity in such things as feeling solid and grounded, feeling comfortable with their beliefs and actions, feeling anchored, the ability to stick by their values, knowing where to draw the line on issues, feeling bold about expressing Christian values, and knowing that something is the "right" thing to do. 88 Others gave specific examples of what their grounding beliefs are and noted that these beliefs guide their actions. Several spoke of a fundamental belief in free will and personal choice, which carried through in their work with clients engaged in behaviours they believed to be wrong. One participant noted his firm belief that religion and science are totally compatible, and that seeming discrepancies between the two should not be viewed as a threat, but rather as a challenge to explore the issues further in both domains. Another participant expressed the importance of working out of the belief that we live in an imperfect world, and that we do not need to have all the answers to be of help and service to others. For all, this coming to clarity in their beliefs resolved values tensions around not knowing what to think or how to act. #1 I feel more secure about being able to articulate why I do what I do. I don't feel as threatened by other peoples' judgments of me. So I can...just stand more solidly on my own two feet...If somebody doesn't like what I do or thinks differently, I'll be able to understand where they're coming from with that kind of judgment and not feeling I have to respond to it or to change my behaviour because of it. #10 So that probably made the biggest difference for me... just to finally acknowledge...be really clear on what I was believing. And since then 89 the tension hasn't been as great because I feel like I'm more solid in my own spiritual growth at this point so that I'm not struggling as much right now. #4 Knowing what I believe and that was a journey... I think I front-loaded a whole lot of work in terms of my belief system... [and] when the situation comes up you recognize it and then certain things snap into place which make it easier. It's not like its new territory. #5 But I believe so fundamentally in free will and in God having created us as people who are to initiate and choose. Acquiring knowledge, training, & experience This category contained 36 critical incidents that described various ways of acquiring knowledge, training, or experience and emphasized the overall importance of continued learning in helping to resolve tensions. Increased knowledge led to greater understanding of the values issues and increased the participants' ability to think things through with greater clarity. Formal university education and clinical training were helpful for many. Some talked about their university programs and courses that exposed them to philosophical, ethical, and theological issues relevant to the exploration of value 90 tensions. Clinical training and experience was noted as an important helping factor in helping some participants come to a deeper understanding of religious values, or as an encouragement to self-reflect and explore uncomfortable issues. Specialized studies within a Christian context were also noted to be helpful. Some studied in Christian universities explicitly focussed on integrating psychology and theology, where religious values and practices were openly discussed and affirmed. Several mentioned that formal studies in theology helped by deepening their understanding of how psychology and theology interact. One participant related that this provided a greater sense of confidence in defending the legitimacy and efficacy of psychological theory and practice when dealing with Christians opposed to psychology. Many participants were avid readers and noted particular books that helped in the struggle. Some mentioned that what they were reading provided insight into specific issues, for instance, reading about the etiology of homosexuality helped one participant understand the psychological and spiritual aspects of the homosexual lifestyle and behaviour leading to greater facility in working with these clients. Reading, for others, illuminated the whole area of integrating psychology with faith issues. Other books provided affirmation and encouragement to pursue their own ideas about spiritual issues. Within this whole category of acquiring knowledge and training was the sense of an opening and expansion of knowledge around the issues involved in struggling with values tensions. 91 #2 I think my training in terms of more psychodynamic kind of training also helped... sorting out ...the issues of transference, countertransference. And all the feelings that are involved. All those helped kind of process more what's going on. So using that mould in examining myself. I think the psychodynamic or the psychoanalytic kind of tradition has been a very big benefit to me in terms of continually examining myself... Where am I? What's going on? Why am I doing this? Why am I thinking this way? Why am I feeling this way? All that becomes a process ... that has helped me sort things out. #9 Most of this stuff I leaned in my... ethics course. #3 I was trained in a Rogerian background and that was pre-Egan. It was Carkuff and Truax who were disciples of Carl Rogers. When I read Rogers I thought this is the gospel manifest. I found his writing and his way just transformational for me. I thought it was remarkable and it evidenced much of the Scripture. 92 #6 I think probably, the other thing that has factored in is... I went to seminary before I did a doctorate in psychology...[and worked] as an associate pastor before I got into this field. So my roots are more pastoral ...I think what we discover in psychology and what works with clients is something that God has created to work... I think that in light of those things, with that background, it makes it easier for me to go in that direction with a client. #1 And I remember as well reading a book.... It's a Christian apologetics book, and his fundamental tenet was that all truth is God's truth no matter where it's found. And it really seemed to ring true for me. So I don't think God is threatened by us trying to understand ourselves better and learn how to live better lives. So that's one of the ways that I have worked to resolve that tension. Engaging in a process of self-reflection/growth This category contained 33 critical incidents in which participants made some reference to being in a process of growth and development. They recognized tensions as a normal part of one's development that required working through. Some had not come to complete resolution of the tensions but they recognized the 93 necessity of actively engaging in the process. Participants used many action oriented words to describe this sense of engagement: struggling, growing, reflecting, examining, questioning, wrestling, thinking, engaging, figuring things out, working on things, personal development, or an active process. This process of self-reflection and personal growth led to a greater sense of understanding, grounding, and clarity in beliefs and values for many participants. One stated that the process of personal growth provided a greater sense of security and confidence in beliefs. Another noted that the struggle led to greater ability to deal with contentious issues such as abortion. A third participant related that wrestling with the issues resulted in resolution of uncertainty regarding how to deal with people living a gay/lesbian lifestyle. The participants noted that the process was important, even though it was very difficult at times. #1 I think that it's personal growth to a large degree.... So it's a matter of personal development, personal growth, I think more than anything. #2 I think in my whole process of my own special walk and my own personal development.... Yeah, so I'm still working through that and thinking, questioning. You know, am I doing the right thing, or am I doing the wrong thing. 94 #10 But it was like for me I needed to go home and sort of just wrestle with this and say OK so what is all this about and no, I'm not here to discuss her lifestyle and she's not here to discuss my lifestyle. But we're here together to both learn from each other. And so when I was able to approach it like that, that was fine and it worked really well.... But for me those were really positive experiences because I just... took the time to really think about it and didn't want to make it into an issue. #12 And really, I don't think I really felt settled and happy about being a psychologist as a Christian until 20 years later. You know, it was a long, long process and I think partly because the issues that I grappled with... the way the culture understands psychology based on very.... I think non-Christian worldview assumptions. Clarifying goals and roles There were 22 incidents in this category about gaining clarity about one's role and goals for clients as a means of dealing with tensions. Some of the incidents focus on being clear about one's role and responsibilities in the therapeutic relationship. This allowed participants to let go of things that they perceived were 95 outside the bounds of their role. One participant noted that it is not the role of a psychologist to be the gatekeeper for other's moral choices. Others related that they are not responsible for clients' choices. An important issue for some was how to handle the scriptural directive to evangelize, that is, to share with others about Jesus and encourage them to adopt Christian religious beliefs. Most resolved this issue by concluding that it is not their role within a therapeutic relationship to promote their religious views and therefore this teaching regarding evangelizing did not apply in the therapeutic setting. Being clear on one's role included developing clear goals for the therapeutic relationship that did not involve imposing moral values on clients. Typical goals mentioned were to alleviate suffering, to help in the process of healing, to facilitate change, to help clients deal with issues and to increase clients' awareness about the pros and cons of various choices. Several also mentioned the need to maintain clear boundaries with clients about the goals and role in the relationship. Being clear on goals and role led to a decrease in tension as these particular goals and roles are consistent with values of professional practice, whereas any goals related to the need to share one's faith or moral values would directly conflict with professional ethical practice. #3 I do not have to evangelize Mongolia. It is not my job. People say well don't you have to evangelize everybody? It's just not my job. 96 #11 I think that was a watershed point for me in terms being able to step back and say yeah, that's not my role, that's not what I want to do. If God wants to provide a way of salvation to these people maybe by alleviating the suffering they will be more open to that but he's going to have to pick somebody else to do that. #8 But my goal is not to convert people. My goal is to help in the process of healing.... And, for me I do think I resolve a lot of the conflicts between the ethics code of my profession and my Christian ethics in terms of looking at my role. #9 With those people there comes a point where I can't go any further. Because I can't.... I won't cross that line of saying to them, well... you're living your life wrong and you're selfish and you're totally self-centred, I won't cross that line. Promoting client choice and responsibility There were 12 incidents that described another aspect of being clear, that acknowledging that ultimately clients are responsible agents. Participants spoke 97 about respecting client choices and allowing clients freedom to choose. Even when clients were engaged in behaviours contrary to the participant's values, participants were mindful that ultimately the client was responsible for his/her own behaviour. Free will and choice were often held up as important values that the psychologist held and they spoke about ways in which they tried to infuse these values into the counselling relationship. The rationale for these values was given as both a religious belief and also a professional directive. Accepting a client's right to choose allowed the psychologists freedom from feeling responsible for client's moral choices. This helped to lessen values conflicts when doing therapy with clients engaged in behaviours such as same-sex relationships or abortion. #3 I think this pro life/pro choice thing is pathetic because one of the highest Christian values is choice. It's not coercion and I think the code of ethics would have a similar perspective on that. #5 Because that's a foundational value for me, that people would choose. #8 And so even as God gives us clear choices and gives us the freedom I think it's my responsibility as a therapist to also ethically be very 98 clear... to give people clear choices and the freedom to make those choices for themselves. #11 I'm just allowing myself to recognize that that is their choice, their responsibility and many times making it clear. Using self-disclosure to facilitate client empowerment There were 11 incidents in which participants reported using self-disclosure to deal with conflicting values between themselves and clients. Most of the incidents related to participants wanting to be open and honest when working with clients engaged in behaviours such as same-sex relationships, abortion, and divorce, where they experienced a conflict in values. The psychologists were concerned that their own values might impact negatively on the therapeutic process. They handled this by sharing their beliefs and/or biases with the client and giving the client choice about whether or not to continue in therapy or be referred to someone else. #2 And even for people to come in and say that I'm not comfortable with my homosexual struggles and I will tell them, you know, these are my biases ... these are my values and... anytime you don't feel 99 comfortable with me then ... you have the right to not continue with me. #5 I talked to him and said something to him about my being a Christian, working from a Christian value system... I don't think I told him that I wouldn't see him, but he chose not to see me. But I resolved the tension by saying, in essence, we've got a gap here and I don't know if we can bridge it. #8 And I mean the tension in there in part is yes when a client comes and is fully committed to a lifestyle I disagree with, there's a tension there because I know I can't be supportive of that and that's where it's important for me to honest. And say, you know, I'm not going to be able to help you in these ways because I just can't go there with you. Managing amount of engagement This category contained 11 incidents that described how therapists can sometimes manage their level of engagement in situations that involve tension. A few of the participants noted that they work in a Christian setting where their Christian values are more explicitly known and most of the clientele share many of 100 those religious values. This limits the likelihood of working with a client whose values clash greatly with those of the psychologist, which was one area of tension expressed by many participants. Some participants talked about things like 'avoiding,' 'withdrawing,' or 'compromising' in difficult situations in either the Christian or secular communities. One participant spoke about avoiding religious people who hold very fundamental views on many issues and refuse to entertain alternate ideas of Christian morality. Another participant spoke of using compromise in his response to a client who wanted help with a sexual relationship outside the bounds of marriage. In this manner he was able to provide some assistance to his client without compromising his own beliefs. Several participants reported that they either avoided or withdrew from situations such as dual relationships in which there was a potential conflict in values. #3 Well I don't hang around religious people much... I just don't do it.... So one of my coping strategies is to stay away from people who won't think through the issues. #4 Yeah and plus I guess it was a compromise to me, I gave the guy [a book]. He can read about it. That's where I drew the line at that point. I don't want to continue to support him in this behaviour and implicitly 101 and explicitly say I'm going to help you do something wrong better. You can go ahead and read and that's your own initiative. #11 I remember one time we got together for Saturday morning men's volleyball, and looked around and here my teammate was a client and that was a problem. It might not have been a problem for him but was for me. I resolved that one I think by not going back to volleyball. #5 I've got it easy because most of my clientele is Christian and so in that regard I have free form to assume shared values more or less on the biggies. Engaging in Spiritual Disciplines This category contained 15 incidents related to using spiritual disciplines to help resolve values tensions. Spiritual disciplines are concrete activities that can be enacted to draw one closer to God and to pursue the mind and will of God (Tan & Gregg, 1997; Willard, 1988). There is some connection between this category and that of "Following God's Teaching/Open to God," as these practices led to being more open to God's leading, which in turn would facilitate resolving the conflicts. 102 Participants talked about some activities that helped them work out tensions, such as prayer, fasting, and journalling. Prayer was the most common activity mentioned and is central for many in dealing with the struggles over value tensions. Participants spoke about praying for guidance, clarity, wisdom, strength, acceptance, and answers in dealing with these conflicts. Some mentioned the need for individual prayer as well as the need to pray with others in their faith communities. Several participants mentioned the benefit of praying for clients outside of therapy sessions as a way of dealing with their own concerns about the moral choices clients were making. Several participants also noted that they use fasting and journalling as ways of achieving direction and clarity on some issues. #4 Considering it prayerfully... So there is a gut emotional level and then to bring it to a higher level... So yeah, to answer your question there was a lot of prayer and fasting. #3 I always write down my values. I never thought to tell you that. I am always writing down a hierarchy of values. Not the Maslow values but my own personal values. 103 #5 But I do journal and I do pray and I do journal when I'm stuck with clients and I need to work through some deep countertransference in me to see what it's saying about the client. I will pray and journal and think hard. Possessing personal qualities Seven incidents described personal traits or qualities that the participants relied upon to help them deal with these tensions. Having a sense of humour was essential for one participant as a means of lightening things up to avoid getting bogged down in the values conflict. Remaining humble about one's understanding of truth, specifically, knowing fully the etiology of homosexual behaviour, was important for another. This allowed the participant to be more open to scientific theories and to consider more factors when trying to integrate a scriptural perspective on this issue. Strength of character was mentioned by a third. This participant reported that this helped prevent him giving in to pressures to adopt a view on a particular issue that was contrary to his moral beliefs. Other personal qualities that participants mentioned as being helpful in dealing with tensions were being genuine in terms of living out Christian values, having a questioning mind that noticed issues and continually pushed for answers, and using common sense to come up with reasonable explanations. 104 #7 Oh yes, humour is in fact my very survival in life...I don't think I would have survived... Yeah, to lighten things up. And to escape from the pain to some degree too. #8 I want to be more humble...l believe in God's word, I believe in God's truth, I believe God's truth is absolute. I'm not willing to accept that in my humanity I fully comprehend God's absolute truth. I have no problem and no question that God's truth is absolute. But I am not about to say that my person...me...knows that absolute truth 100% accurately. I still believe that we see through a glass darkly. When we get to heaven then I'll probably be able to accept that I know something 100% accurately. But until then I'll take a more heuristic or scientific approach to my faith, which is all the data from Scripture, all the data from Christian tradition, says this is true and right. But the best I can say is this is true and right to the best of our understanding today and God can always come in tomorrow and say: 'But you know what... you're missing this'. #9 Well, I couldn't give in, I mean just my own strength of character... I know what's right. 105 Accepting and seeking out challenges The 9 incidents in this category speak of a positive attitude toward feeling tension or being challenged by some event, situation, or person. One participant reported his belief that tensions are good if people are willing to engage in them. This participant invited tension as it provides an opportunity for growth. Another participant, who worked in a Christian training centre, mentioned being challenged by some of his students who wanted practical instruction on how to integrate faith and practice. This participant responded to the challenge by experimenting and learning how to do the integrative work. Other participants noted feeling challenged by other Christians who hold very fundamentalist views, or being confronted with people identifying themselves as gay or lesbian. In all cases the psychologist used these challenging events as an encouragement to think things through, which resulted in a lessening or resolution of the tension. #3 Tensions are very good. Tensions allow for the best teaching and the best preaching, the best counselling, the engagement of tension. By the way my background I was always trained to placate tension or empathize with it and to take it away. What I've learned to do is to increase it and then see if you enter change. I see it in me so when I 106 have tensions of belief or disbelief I don't mind reading, thinking, studying, talking it out... I know there's some tensions in the Christian faith and psychological practice but I don't worry about it. I sleep fine. #6 It has resonated particularly with the more evangelical students that we've had...and they want to learn how to do it clinically [integrating faith and practice], they don't just want to learn it on a theoretical level...It makes me step up to the plate, because somebody's got to do it...if it's a featured part of our program I think that we sure as heck ought to be teaching students how to do it. #10 And she was good because I think she [lesbian woman] challenged... some of my spiritual beliefs.... And I thought that's good because I have to think about this and I have to wrestle with this and be able to provide her with an answer that's satisfactory to me. Accepting people There were 5 incidents that expressed another aspect of being clear about beliefs and values. The focus in this category is learning to accept people where they are rather than judging them for their behaviour. This acceptance of people 107 appears to be an orienting, basic core value for some. This was sometimes mentioned in the context of recognizing common humanity rather than focusing on an identity controlled by lifestyle or behaviours. For example, recognizing people who are engaged in homosexual behaviour not as "just homosexuals" but foremost as valuable human beings. #2 I think...to understand where they're coming from, how they got where they are... not to judge them... I guess to stay with them as people who are struggling... and to work with them as people who are struggling. #11 I guess one of the things that's probably influenced me to a degree is that that hospital was a downtown core hospital in a neighbourhood that had a large gay population so a significant percentage of the people I was seeing for psychological assessment, personality assessment, neuro-psych assessment and so on were from the gay community. I guess I got to see them as kind of real people who have real issues and not so horrible and scary. 108 Hindering categories Five categories were formed from the 51 incidents that participants thought hindered their ability to deal with the values tension. The categories are: my own disruptive reactions, antagonistic beliefs and biases, lack of understanding and support, not knowing, and legal concerns. My own disruptive reactions There were 16 incidents in this category, which described personal reactions respondents had that interfered with resolving tensions they experienced. Some participants mentioned being fearful about doing something wrong that might harm a client, which made them hesitant to attempt any spiritual interventions with clients. Others noted fear of being judged negatively or criticized for expressing conservative religious beliefs. This held them back from expressing their religious values and feeling blocked to some extent in exploring the values tensions. Other disruptive behaviours were noted as being overzealous about sharing beliefs or wanting to preach to clients, and negative reactions towards client behaviours. Experiencing pain and ambivalence about not being able to share his beliefs with a client about the need for salvation was poignant for one participant. These incidents highlight the difficulty psychologists encountered in trying to keep their own moral values and beliefs out of the therapeutic relationship, even when they felt, ethically, it was necessary to do so. 109 #6 Other hindrances would be the fear that I might be doing something that's genuinely wrong... and I think that's partly because there's not a great body of knowledge that's being agreed upon by a large number of folks, you're kind a left groping in the dark. So, that fear that it would be wrong or inappropriate, the fear that it may be damaging or not beneficial...So, that fear of failure would be a part of it. #1 One possibility [of a hindering factor] might be concern about how other professionals might view me, particularly ones who are not Christian psychologists, or Christians... whether or not they might see my point of view as flaky or just not... thoroughly thought through. I must confess that there is a certain amount of anxiety that I carry, and I suspect that it's true for everyone, about...wanting to be viewed as competent or adequate. And that may play some role in hindering my... coming to a really... balance point on this thing of resolving this tension. #8 There's a part of me that would love to be a preacher.... And growing up and being part of a conservative evangelical Protestant faith there 110 are times when, yeah, I want to preach and I want to be a prophet and I want to be all those other things. #4 Oh, profound ambivalence about going back into the fray again, oh my gosh! ... When I see patients and they are not Christians, it is absolutely painful to know that I'm having an intimate encounter with them and they're lost. Antagonistic beliefs and biases The 13 incidents in this category related to how the participants were affected by negative beliefs or biases, within both the secular and Christian communities. Participants noted a general bias or negative stereotypes held in society against a conservative Christian perspective. Some felt this bias in mainstream psychology when considering some issues such as homosexuality, in which a Christian moral position is not at all accepted. It was also noteworthy that some felt antagonism from other Christians who hold very narrow or fundamentalist views on many issues. People who have these fundamentalist views can be totally unaccepting of psychology itself and are often very black and white in their beliefs about some behaviours, such as homosexuality and abortion. 111 A couple of participants related that they had to deal with their own early Christian training, which resulted in them holding a narrow view of some issues. These issues hindered the process of resolving tensions by limiting participants' ability to explore the tensions openly. #8 In the market place of ideas and academia, in the market place of ideas in the profession of psychology you can talk about everything but what comes from a conservative Christian perspective. You can talk about things from a conservative Muslim perspective; you can talk about things from a conservative Buddhist perspective. You just can't talk about things from a conservative Christian perspective. And that's an inherent bias in the profession. #10 You know in any case... well any groups that I've ever done or case conferencing...if it's a fundamentalist Christian family it's always trashed because it's a fundamentalist Christian family and I get really tired of that... tired of some of the stereotypes that are out there. That's a biggie... that's been a big hindrance. 112 #9 And because my view [regarding homosexuality] is the politically incorrect one... because the mainstream idea is different than mine, I can get in trouble for holding my views... for most psychologists my position would not be defensible because they don't agree with it, not because it's not defensible. #11 Well my early bias... I would get quite worried or concerned if I was working with either an individual or a couple and there was some possibility expressed of separation or divorce because of my own somewhat naive I guess assumption that... marriages stay together at all costs. Lack of understanding and support The 14 incidents in this category reflected a hindrance to dealing with tension or possibly an increase in tension resulting from a perceived lack of support. This was evident through family members being in opposition to one's religious views, being treated with scepticism for holding views different from mainstream psychological theory, feeling misunderstood by both Christians and non-Christians, and lack of Christian role models. Feeling unsupported hindered the resolution of values conflicts by blocking the sense of freedom to explore issues, by feeling 113 isolated in the struggle, or by creating questions about whether or not to remain in the field of psychology. #7 [I] had a lot of tension also because my wife was not and still is not a Christian... I wanted to go work in a Christian counselling setting and she didn't want me to do that cause that was too much acknowledging I was a Christian for her, so I put that off for a little while and... because of the tension of that I actually quit counselling for a period of time. #9 What hinders? The whole world of psychology, most of my professors, in fact I think I was looked at with huge scepticism because I was questioning it. And it was clear to them that I was hanging on to my beliefs. And I was clear to them that I did not embrace a relativistic point of view, that all things were equally good. And they didn't like that. That really made me sceptical... Oh yeah! And all my fellow students, there was no one there either. #12 I sometimes feel like I walk this fine line between being perceived by some people as just, you know, a devil, and other people as this 114 'Pollyanna-ish', head-in-the-sand Christian...! found that out in the general community but I also, unfortunately, I even find that among psychologists and Christian psychologists sometimes too. And maybe it's me, I don't know... it does cause me to doubt myself. #10 I've always wanted a good Christian role model in terms of a Christian psychologist kind of a person. I've yet to find that... so you know that makes me sad. Not knowing There were 6 incidents in the category of not knowing. Participants mentioned that lack of knowledge from a religious or professional perspective, or knowing how to approach an issue was a hindrance to resolving tensions. This reflects the idea that knowing more might have provided more insights and capability to deal with the tensions. There are various things that influenced the not knowing, such as, their own lack of training or experience, lack of research into many religious issues, not taking the time to investigate ethical standards, and the ethical guidelines themselves being vague and not addressing issues specifically. 115 #7 Just my ignorance about Biblical understanding and who God was and how he operates and those kinds of things. As I learned that more and more any other hesitations gradually just fall by the wayside as they become irrelevant. #1 Maybe one of them is simply lack of certainty about what's ethically appropriate, particularly chasing bad debt. It's probably more of a personal issue than anything else, but I just haven't taken the time to really investigate with the [licensing body], what the standard rule of thumb is about that. #10 And then the fact that a lot of the ethical guidelines are still so vague that that's a hindrance I think in some ways - that you still have to ultimately wrestle with... what can I do morally and.... for myself in those grey areas.... and there's so many of those. So that has remained a hindrance. Legal concerns Two participants spoke about the legal ramifications of their actions as a hindrance in that the state holds significant power to influence one's actions. This 116 appeared to result in avoidance of dealing with the values tensions. Although this category had only two incidents, it was decided to keep this category, as these are important issues, especially for those participants living in a more litigious climate like the United States. #6 And there are people that are losing their jobs over this stuff in places, so there is a very real risk, you may counter sue and win that law suit and everything else, but do you really want to invite that much pain into your life and all the expenses and everything else. #8 Well, I think the biggest thing that hinders me is the State does have the ability to take my licence. The State does have the ability to impact me financially and in every other way. And so the tension is to do what's right or to do what is legally safe. Validation Procedures The validity of the categories was ascertained by the following procedures: (a) independent extraction, (b) expert validation, (c) participants' crosschecking, (d) independent raters, (e) exhaustiveness, (f) participation rate, and (g) theoretical 117 agreement. Each of these procedures will be examined in this section. Independent Extraction of the Critical Incidents An independent rater (a graduate of the UBC MA Counselling Psychology program, familiar with CIT and spiritual issues) read three of the transcripts and highlighted the helping and hindering incidents. The rater read the transcripts of an early interview, one in the middle of the process, and one of the last interviews. In the first transcript we had an initial agreement rate of 71% and for each of the other two transcripts, the agreement level was 83% (a mean of 79% agreement). The differences resulted primarily from my finding more critical incidents than the rater and also, to a much lesser extent, the rater identifying incidents that I had not. I discussed each of these transcripts with the rater, reviewing the discrepant incidents. In all cases we were able to agree on the inclusion of the discrepant items. Expert validation An early procedure to ensure soundness of the categories was to ask experts in the field for input. Two experts, both professors in Christian graduate counselling programs, and both with experience teaching ethics, were asked for feedback on the relevance and usefulness of the categories as exemplars of experiences they have encountered in the course of their work or research. A letter was sent to each (Appendix G) asking them to review the formed categories and comment on their relevancy and usefulness. 118 The first expert commented that all the categories made intuitive sense. He asked if anyone had alluded to the guidance of the Holy Spirit in the categories. There were a couple of references to this, which were placed in the category "following God's teaching/open to God," but there were insufficient incidents to make this a separate category. This expert had no further suggestions for areas that are missing. The second expert rater also endorsed the categories, stating, "These categories are highly relevant and ... accurate of the tensions I have encountered myself and know about from others' encounters. These theme descriptions are likely to be quite helpful to many people who experience such tensions." He also made some specific suggestions for clarifying the names of categories and many of these were adopted. The category "Experiencing Support" was changed to "Experiencing Direct Support," "Being Clear on Goals/Roles" was changed to "Clarifying Goals and Roles," "Being Clear on Beliefs" became "Formulating Beliefs and Commitments," "Promoting Client Choice," became "Promoting Client Choice and Responsibility," "Other Things that Helped" to "Engaging in Spiritual Disciplines," "Using Self-disclosure" to "Using Self-disclosure to Facilitate Client Empowerment," "Accepting Challenges" to "Accepting and Seeking Out Challenges," "Lack of Understanding/support/isolation" to "Lack of Understanding and Support from Others," "My Own Reactions" to "My Own Disruptive Reactions," and "Beliefs and Biases" to "Antagonistic Beliefs and Biases." 119 Participants' Cross-checking The participants were asked to review the findings describing both tensions and categories for input into the accuracy of the reported transcript excerpts and to verify that the category descriptions correctly reflected their experience. This step is consistent with the stated aim in this study to give participants "voice." The participants are experts in their own history and perspectives and this input helps to guard against the potential biases of the researcher in omitting or distorting the categories. In this manner I was able to check my interpretation of the transcript excerpts and the forming of categories based on my understanding of the meaning of the participants' words. Taking the data back to the participants is also consistent with Maxwell's (1992) concept of interpretive validity. I contacted participants by phone or e-mail and all agreed to take part in this validation process. I sent each a letter outlining the process (Appendix H), a document summarizing the tensions that particular participant described, and a second document outlining the categories and transcript excerpts. All except one of the 12 participants responded and these 11 endorsed the categories as an accurate reflection of their experience. Some participants made suggestions for minor changes in the wording of the transcript excerpts and these changes were made. The participant who did not respond was contacted by e-mail and informed that his interview material would be used in the final analysis and write up unless he contacted me regarding any concerns. There was no further contact with this participant and no reasons given for the lack of response. The three participants (Group B) who did not fit the criteria and, therefore, 120 were not used in the analysis of the data were sent a letter of instruction (Appendix I) and a summary of their interviews and were invited to provide comments regarding accuracy and interpretation (note: the data for Group B is in Appendix K). Independent raters Following the formulation of the categories, two independent raters were asked to sort a random selection of critical incidents into the correct categories. One rater has a PhD in Counselling Psychology and the other is a PhD student in Counselling Psychology. Both were familiar with the Critical Incident Technique. A sample size of 53 incidents was randomly chosen from the total pool of incidents. Three incidents were selected from each category by numbering the incidents in each category and using a random table of numbers to select three. Random selection was not done with the category "legal concerns." Since this category contained only two incidents, both were included in the validation procedure. The description of each category was reviewed with each rater and then these categories were laid out on separate pieces of paper on a table. Each incident was also put on a separate piece of paper and the rater was asked to place these incidents in the category they thought was appropriate. The raters worked independently and took approximately 60 - 90 minutes each to complete the task. Both raters exceeded the minimum 75% level of agreement suggested by Flanagan (1954). The first rater's agreement was 87% and the second, 83%. After the sorting process was completed, the incidents that were incorrectly placed were discussed with each rater. In all cases, the discrepancy was resolved by providing 121 the rater with more of the context surrounding the incident. Exhaustiveness Andersson and Nilsson (1964) addressed the issues of comprehensiveness and saturation. They found that, in most cases, the categories become apparent after a relatively small number of incidents had been classified and that most of the remaining incidents could be placed within these initial categories. When no new categories are formulated by adding more incidents, it is concluded that a saturation point has been reached and the categorization process is complete. Following McCormick (1994), approximately 10% of the incidents (i.e., the incidents from participant #6, which totaled 30) were held back until all the categories had been formed. These incidents were then examined and easily placed within the existing categories, confirming that saturation had occurred. Participation rate Participation rate can be calculated by adding the number of participants who endorsed each category and calculating the percentage of participation. Flanagan (1954) suggests that the higher the participation rate, the more valid the category. Borgen and Amundson (1984) suggest that 25% participation is sufficient to establish validity of the category. All categories except one had a participation rate of at least 40%. The category of "legal concerns" was mentioned only twice, with a participation rate of 17%. However, it was decided to include this category with the caveat that it has not achieved the 25% participation rate chosen as the cut off for 122 validity. Table 2 (earlier in this chapter) presents the categories with total number of incidents reported and participation rates. Theoretical agreement Comparing the findings with relevant literature helps to assess the soundness of the categories (Flanagan, 1954). There are no studies that explicitly examine the interplay between Christian values and professional ethics codes. However, some studies make inferences that relate to this research question and other conceptual literature addresses some of the issues reported. An overview of both the research and conceptual literature was done to determine support for the categories developed in this research. Grappling with a value tension is a stressful process and there are many ways one can cope with this stress. Although there was nothing specific to coping with value tensions found in the literature, there is research that addresses how psychologists cope with personal and interpersonal stresses and maintain their own well-functioning. There are many parallels between this coping literature and the present study. Other literature that supports the categories will also be noted. This includes writings and research on self-care, ethical practice and master therapists. Experiencing Support/ Lack of Understanding and Support. The importance of social support has long been recognized as a helpful factor in coping with any kind of stress (Lazarus & Folkman, 1984). Coster and Schwebel (1997) report that support - from peers, from family, and in supervision was found to be a critical 123 component of well-functioning in psychologists. Pargament, Smith, Koenig, and Perez (1998) note that seeking support from clergy and church members is an important dimension of coping for religious people undergoing life stressors. These studies lend support to the helping category of "Experiencing Support" and the hindering category "Lack of Understanding and Support from Others." Following God's Teaching/Open to God. Walker, Pitts, Hennig, and Matsuba (1995) interviewed 80 people of diverse ages (16 - 84) and backgrounds to explore their understanding of morality. One of the notable findings was that, for many of these participants, morality was firmly embedded and governed by their religious faith. Case and McMinn (2001) noted, that for religious therapists, "religion is embedded in their guiding framework for living" (p. 31). Many people use religious coping in times of stress (Pargament, Smith, Koenig, and Perez, 1998). Pargament, Smith, Koenig, and Perez (1998) identified positive and negative patterns of religious coping. Some of the items these researchers identified as positive religious coping are: "looked for a stronger connection with God," "sought God's love and care," "tried to put my plans into action together with God," and "tried to see how God might be trying to strengthen me in this situation" (p. 718). Maloney (1986) suggested that Christian mental health professionals centre their ethics on a higher value (identified as "love"), whereas secular codes are based on an ethic of "justice." These findings are consistent with the expressions of following God found in this study. 124 Formulating Beliefs and Commitments/Clarifying Goals and Roles. Oordt (1990) noted that integrating faith and practice into therapy practice must be a deliberate effort. "It requires thinking through the ways in which Christian principles might apply to the situations faced in the practice of therapy" (p. 260). All of the participants in this study spoke of this process, which led to being clear on their beliefs, commitments, goals, and roles with clients. Acquiring Knowledge & Training/Not Knowing. Baron, Byrne, and Watson (1998) found that one of the ways people reduce cognitive dissonance is to acquire new information. Skovholt, Grier, and Hanson (2001) reported that professional expertise is an important part of self-care for counsellors and can be achieved by continued learning. Jennings and Skovholt (1999) noted in their research on master therapists that these therapists are characterized by a voracious desire to learn and are continually engaged in professional development. Participants in this study spoke of the need to learn in their graduate training and also continuing this in their professional lives. "Not knowing" was listed as a hindrance to dealing with tension and the psychologists who spoke about factor implied that this became an impetus to read or study further. Engaging in a Process of Self-Reflection. Critical self-reflection is one of the central tenets of a "responsible practitioner" as defined by Tennyson and Stromm (1986) and is essential is maintaining ethical practice. Case and McMinn (2001) administered a questionnaire to psychologists to determine what factors contribute 125 to the ability to function well. "Self-awareness/self-monitoring" was one of the most highly endorsed items. Self-awareness and personal values are recognized as important items in a well-functioning person, and psychologists in particular (Case & McMinn, 2001). Jennings and Skovholt (1999) also noted that self-awareness was a sign of emotional receptivity, which was an important attribute for master therapists. Many of the participants in this study appeared committed to "Engaging in a process of self-reflection and growth" and found this an important way to work through the value tensions they experienced. Promoting client choice. Haug (1998) noted that maintaining client autonomy can be a concern when including a spiritual component in therapy and must be carefully monitored. Upholding this autonomy and choice is a value emphasized in most ethics codes (American Psychological Association, 1992; Canadian Psychological Association, 1991). Jennings and Skovholt (1999) reported that master therapists "have a deep respect for their clients' right to self-determination" (p.8). The importance of this issue was addressed in this study by many of the participants. Using self-disclosure. Self-disclosure is recommended in many ethics textbooks as a way to manage incidences of value conflict (Bersoff, 1995; Corey, Corey, & Callanan, 1998). Hawkins and Bullock (1995) suggested that being open with clients about beliefs and values is one way to ensure that religious values are incorporated into therapeutic interactions in an ethically appropriate way. These 126 authors also indicated that this could best be done at the beginning of therapy as a part of the informed consent procedure. More than half of the participants in this study used self-disclosure to share their moral values with clients. Managing amount of engagement. Lazarus and Folkman (1984) describe emotion-focused forms of coping as including the use of cognitive processes to lessen emotional distress. Included in the list of strategies are avoidance and distancing, which are strategies consistent with participants' descriptions in this study of managing how much they engage in tension-producing situations. Engaging in spiritual disciplines. Practicing prayer or meditation was found to be a common source of coping among psychotherapy practitioners (Mahoney, 1997) and for some psychologists, their first resource (Case & McMinn, 2001). This was one of the spiritual disciplines noted by many of the participants in this study. Possessing personal qualities. Lazarus and Folkman (1984) note that using humour is a coping strategy that helps to regulate emotion. Jennings and Skovholt (1999) reported that striking a healthy balance between confidence and humility was important in the maintenance of mental health for master therapists. Maintaining a sense of humour and humility were two of the personal qualities participants acknowledged in this study. Seeking Out Challenges. Positive reappraisal is the process of focusing on 127 the good in what is happening. Folkman and Moskowitz (2000) note that appraising situations more as a challenge than a threat changes the meaning of a situation allows a person to experience positive emotion and psychological well-being. Participants in this study may have been engaged in positive reappraisal strategies when they described using challenging events as opportunities to grow and learn. Accepting people. A central tenet in Rogers' Person-Centred Therapy is the need to accept clients unconditionally to help facilitate change and healing. Five of the participants talked about their commitment to dealing with people as they are and that coming to this belief relieved tension. My own disruptive reactions. Kinnier (1995) notes that some affective responses are maladaptive in resolving values conflicts. Although Kinnier does not cite specifics, these would likely include many that the participants in this study noted: fear, doubt, and overzealousness. Antagonistic beliefs and biases. Oordt (1990) discusses the impact of feeling caught between fundamentalist views and the views of one's professional association over an issue such as homosexual behaviour. He notes that psychologists who are facing strong views on both of these fronts are likely to find it difficult to know how to integrate their professional standards with their Christian values. Narrow beliefs around issues like homosexuality were noted as a hindrance for some participants to dealing with tension. 128 Legal concerns. Legal issues are often addressed in ethics training and ethics textbooks (Bersoff, 1995; Corey, Corey, & Callanan, 1998). Corey, Corey, and Callanan (1998) emphasize the need to be aware of the legal implications of clinical practice. In many areas, including British Columbia, psychologists must pass a jurisprudence exam as part of the registration process, accentuating the need for psychologists to be knowledgeable about relevant laws. Although there were only two incidents, this category was not dropped because it was decided that this is an important area to consider in ethical practice. Summary In summary, analysis of participant interviews identified common tensions among Christian psychologists. Thirteen helping categories and five hindering categories described factors that contributed, both positively and negatively, to dealing with these tensions. The categories were validated by means of a pilot interview, independent extraction of incidents, participant feedback, independent raters, checking for exhaustiveness, participation rates, expert review, and literature support. The implications of these results will be discussed in the following chapter. 129 Chapter V - Discussion Twelve participants reported on the tensions they experience between their religious moral values and values of professional, ethical practice and how they deal with these tensions. The points of tension included difficulty integrating their Christian beliefs and psychological practice, questioning whether or not one could be a Christian and a psychologist, addressing spiritual issues with clients, dual relationships, and working with clients who were engaged in behaviours such as same sex relationships, divorce, extra-marital sexual relations or abortion. Data from these twelve participants were analyzed using the Critical Incident Technique. A total of 306 critical incidents were found that facilitated (255 incidents) or hindered (51 incidents) dealing with tension between Christian moral values and values of professional, ethical practice. These critical incidents were placed into 13 helping categories and 5 hindering categories. Information gathered by a number of validation procedures provided support for the validity and reliability of these categories. The helping categories are: (a) experiencing direct support, (b) following God's teaching/being open to God, (c) formulating beliefs and commitments, (d) acquiring knowledge and training, (e) engaging in a process of self-reflection or growth, '(f) clarifying goals and roles, (g) promoting client choice and responsibility, (h) using self-disclosure to facilitate client empowerment, (i) managing amount of engagement, G) engaging in spiritual disciplines, (k) possessing personal qualities, (I) accepting and seeking out challenges, and (m) accepting people. The hindering categories are: (a) lack of understanding and support from others, (b) antagonistic 130 beliefs and biases, (c) my own disruptive reactions, (d) not knowing, and (e) legal concerns. This research is about coping with values that clash. More specifically, the participants in this study were dealing with a clash between their religious values and more mainstream values embodied in the ethics of professional practice - the Sacred versus the Secular. In this chapter I will explore the significance of this research in the context of these two sometimes conflicting value positions. The discussion will cover the primacy of a religious worldview for these participants, the importance of feeling supported in their struggle, the use of religious coping practices, practices of addressing values' conflicts, and the process the participants described in dealing with these tensions. I will then address the limitations of this study, the implications for theory and practice, and areas for future research. I will end with an examination of my process in this research project. Religious Worldview It was apparent in all of the participants that moral values were based to a large extent on religious beliefs. This is not unexpected given the selection criteria for the participants in this study and it does reinforce the findings of others who suggest that morality can be embedded in faith practices (Walker et al., 1995; Bergin, 1980; Chapelle, 2000; Richards, Rector, & Tjeltveit, 1999; Bergin, Payne, & Richards, 1996). The importance of this religious foundation was evidenced in the content of the tensions participants described, as discussed further in this section. 131 Religious values were also primary in the areas of spiritual coping and experiencing support, which will be discussed in later sections. As was expected in the reports of value tensions, many participants expressed concern around moral issues that entail the proscription of some behaviours within Christian Biblical tradition. These include abortion, homosexual behaviour, divorce, and extra-marital relations. For many evangelical Christians, there is a definitive "right" and "wrong" in these issues and the participants had to figure out a way to deal with the reality of these behaviours in their clients that was congruent with both their religious beliefs and the tenets of ethical professional practice. The issue of dual relationships was another tension that was expected to emerge in the findings. It appeared to be a more complex issue for these participants than simply finding themselves living in the same small community where resources are scarce and there is no other psychologist available for referral. Participants spoke of a religious value of providing support to other Christians that seemed to override the prohibition against engaging in any kind of dual relationship. As Participant #8 related, "I think there is a sense a commitment on the part of me as a Christian therapist to provide support to the body of Christ. That you support community and that you're embedded in community." In recent years there have been several books written by Christian psychologists critiquing the traditional Western mindset concerning individualism and community (Crabb, 1997; Crabb, 1999; Wilson, 1995). Wilson states that we, in the Western world, hold an ingrained worldview of individualism, which he defines 132 as "prizing the individual over the group" (p. 24) and that Western psychology promotes this individualistic stance. He contrasts this with a Biblical perspective stemming from the fact that people are inherently relational beings and created to live in community. He encourages therapists to carefully consider the implications of dual-relationship issues in the context of this call to community. The participants in this study struggled with this issue of understanding of how they, as Christians, are directed to live and behave in community, while at the same time taking into account the directive in most ethics codes to clearly define and safeguard relational boundaries. It was surprising to me that three of the participants related a deep struggle about whether or not one could be a Christian and at the same time a psychologist. This appeared to be a more fundamental tension than having difficulty integrating Christian beliefs with psychological practice. There is a movement among very fundamental, conservative Christians to oppose any sort of psychological counselling. This is based on a belief that the Bible is the only source of help one should depend on, with no acknowledgement that the science of psychology has anything to offer for increasing one's understanding of the Bible or that there could be any dialogue between the two (Adams, 1970, 1986; Bobgan & Bobgan, 1989). Some of the participants appeared to struggle with these ideas, although they were able to reconcile the tension sufficiently to continue practicing as psychologists. The last question posed in each interview was to ask participants about their view on the relationship between psychology and Christianity. The overwhelming response supported an "integrated view" (Kirwan, 1984), in which the truths of both 133 psychology and the Bible can be incorporated in a harmonious fashion. This is in keeping with Jones (1994), who proposed balancing one's view of the relationship between psychology and Christian theology in his suggestion that these two areas could inform one another if proponents of each entered into a dialogical relationship. The participants in this study demonstrated that they were committed to this process of integration in their attempts to assimilate religious and secular values. Spiritual Coping Not surprisingly, all of the participants identified tenets of their faith as helping them to cope in resolving the tensions. This theme carried through many of the categories and was central to the naming of some of the categories. The category of "Following God's Teaching/Open to God" is explicitly religious in nature, as is the category "Engaging in Spiritual Disciplines." Participants were very open about admitting their dependence on God for direction, for purpose, for modelling, and for wisdom. Participants related that they found this spiritual guidance through reading scriptures, reading books written from a Christian perspective, prayer (both individual and communal), and through consultations and discussions with other Christians. The importance of the spiritual appears central to many participants' total concept of self and it follows that these beliefs would permeate their worldview and most of their decisions. Experiencing tension is a stressful time and these 134 participants echoed their trust in God to help resolve the discordant thoughts, feelings, and behaviours. The area of religious coping (Pargament, 1997) or of spiritual practices contributing to well-functioning (Case & McMinn, 2001) has been studied extensively in the past few years. Pargament (1997) acknowledges that these spiritual or religious resources may be a compelling source of resilience in people whose religion is foundational in their guiding framework for living. Case and McMinn (2001) suggest that "spiritual practices are [psychologists'] first resource for coping with distress" (p. 39), and the participants in this study all related that their religious beliefs and practices were central in sorting out value tensions. Pargament, Smith, Koenig, and Perez (1998) outline methods of religious coping, several of which are recognizable in this study. Some of the participants noted that they believed God had allowed the tensions as a vehicle for growth. This is consistent with the description of "benevolent religious appraisals," which involves "redefining the stressor through religion as benevolent and potentially beneficial" (p. 711). There also appeared to be the use of "collaborative religious coping," that is, "seeking control through a partnership with God in problem solving" (p. 711). Although coping methods used by participants in this study were not exclusively religious, these results affirm the value in considering religious beliefs and practices for coping in general and more specifically in dealing with clashes in values. This religious focus is not something that is generally expressed or encouraged in the secular psychology education literature. Unless one attends a religiously oriented setting for university or clinical training, these religious 135 experiences are not likely to be encouraged or accepted as a reliable source of knowledge or direction. Much has been written about the need to understand and respect the religious and spiritual beliefs of clients; it also appears that it is important to consider this area in the training of psychologists and counsellors. There are two aspects to consider in this regard: a) how religious values are incorporated into one's belief system (e.g., theory of therapeutic practice and ethical beliefs) and b) how psychologists use spiritual practices for coping with distress. Many of the psychologists in this study affirmed that their religious beliefs are fundamental to their worldview and thus to their theories of human change and development as well as to their moral development. This supports the findings of Walker et al., (1995) who reported that religiosity is central for some in the development of moral values. From this study it is clear that religious values can permeate not only scientific theory, but also the practice of psychology, at least for this group of psychologists. If religious values are central to one's functioning as a Christian psychologist, then it is vital that educators learn to recognize this and encourage dialogue in this area among their students. Jones (1994) states "the advancement of the scientific enterprise would be facilitated by making those [religious] beliefs explicitly available for public inspection and discourse" (p. 193). I believe that this open dialogue in clinical training would be helpful in assisting psychologists and counsellors find a way to remain true to their religious values and ensure that they act in an ethical manner. To do this effectively, it is not necessary that teachers and supervisors 136 ascribe to the same beliefs as their students, but rather be open and receptive to religious concerns. Support vs. Lack of Support The issue of feeling supported was a major one for all participants. Close to 20% of the total incidents fell into the helping category of "Experiencing Direct Support" or the hindering category of "Lack of Understanding and Support From Others." Every participant spoke of the need to feel supported and, for some, this was one of the first helping factors discussed in the interview. Both the helping and hindering categories could have been divided into support (or lack of support) from Christian sources and non-Christian sources (the sacred and the secular). About half of the critical incidents in these categories related to feeling supported or unsupported by other Christians, whether colleagues, supervisors, clergy, church members, or friends. The recognition of support from other Christians provided a forum for discussion and a feeling of acceptance or validation due to shared values. Those participants who were trained in Christian universities often noted the benefit of having exposure and encouragement to explore how issues of faith intersected with psychological theory and practice. The lack of support was usually mentioned in the context of feeling unsupported by other Christians either opposed to psychology or not open to discussing tensions. As noted in the previous section, there is some opposition by 137 more fundamental Christians regarding the legitimacy of either the study or practice of psychology (Adams, 1970, 1986; Bobgan & Bobgan, 1989). Participants who encountered this opposition felt confusion or doubt in response to this controversy. Support was not limited to Christian sources and the main issue in feeling supported appears to be a sensitivity and tolerance for diverging points of view and values. Two participants noted that they had supervisors who did not share their Christian beliefs and yet these supervisors were able to help them find a way to negotiate between their belief system and the values of a secular agency. The following quote from Participant #5 highlights the sensitivity and respect this supervisor displayed toward the student: I was under supervision and I happened to have a wise person who wouldn't just make me bad for my Christian values. And so he helped me work it through. And I remember once someone was dying and I felt a tremendous conflict about witnessing to them. You know about wanting to witness to them. And I talked with him and he gave me a way to pose a question that met his standards as the director of a secular university and that met my sense of the patient's need. And so in that sense I was very fortunate to have someone who was wise enough to help me bridge and help me think through. Key in the above example is the participant's emphasis on the fact that the supervisor did not make her feel "bad" for holding Christian beliefs and the desire to act on these. The supervisor displayed a willingness to listen and an openness to deal with values that he himself likely did not hold. Several of the participants talked 138 about experiences or fears of talking openly about their Christian values and being (or expecting to be) dismissed or ridiculed. Case and McMinn (2001) noted that some of the more religious psychologists in their study "feel less accepted within certain professional settings because of their religious orientation" (p.37). Key elements in being supported by either Christians or non-Christians were being heard and feeling accepted for their views. Most participants appeared to have found sources of support in which they could be open about their religious values. If psychologists do not find these avenues of support, whatever values they hold, they may be more prone to negative consequences such as stress, burnout, and perhaps even leave the profession. One could conjecture that there are (or have been) accomplished people studying in the field of psychology struggling with religious values issues (even questioning the compatibility of being a Christian and a psychologist), who leave the profession because they cannot find adequate understanding or support for their religious values. The underlying process One of the limitations of the Critical Incident Method is that the categories are formed and listed according to greatest numbers of incidents. Those categories with more incidents tend to be viewed as more important than those with fewer incidents. In this categorization process, some of the essence of participants' stories can be lost, for example, a sense of progression or growth as participants 139 worked to resolve the tensions. Another way to conceptualize the categories in this study is to note this sense of movement in many of the stories participants told. Some participants spoke of being in the process of resolving the tension and others noted elements that are now in place, and which have diminished this tension for them. The language participants used reflected this process orientation. They used words like "struggle," "wrestle," "grapple," "working through," "working it out," "figuring things out," "thinking it through," "discovering," "a gradual evolution," and as something "I've come to." Some spoke of it in a 'then and now' manner: "And then finally I realized," or "I don't worry about that as much." One participant spoke about the benefits of the process. #12 It was exhausting I would say. When I look back now from this perspective, the perspective of feeling at peace, I think that all of the things that were so hard, I really think they did help to shape me and to get me to this place of peace because I needed to kind of stoke the fire and... see the complexities of the issues. So I don't regret them [struggles], I don't at all regret them. There appeared to be a three-step process in participants' accounts: coming to awareness, a processing, and a resolution (or a beginning, a middle, and an end). In each of these stages there were elements of a mixing of the sacred and the 140 secular. In this discussion, both the religious and non-religious features will be mentioned; however, for these psychologists, the sacred appears to be more vital to the process in many areas. The awareness stage began with recognizing that there was a struggle. This was delineated in the descriptions of the tensions, which were overt expressions of conflict between religious and secular values. The awareness, for some, was a specific point in time, often resulting from being confronted with a client engaging in behaviours contrary to the participant's religious values, e.g., a client engaging in homosexual behaviour or one contemplating abortion. For others this awareness stage was more gradual, such as realizing that there was a struggle between being a psychologist and also a Christian. After the recognition of a tension, participants began the process of working this through. Incidents in the categories of "Engaging in a Process of Self-refection" and "Accepting Challenges" speak to this recognition of a 'work in progress.' The bulk of the incidents are contained in categories describing factors that helped or hindered in this process. These include the helping categories of, "Experiencing Direct Support," "Following God's Teaching," "Acquiring Knowledge & Training," "Engaging in Spiritual Disciplines," "Managing Amount of Engagement," and "Possessing Personal Qualities." The "hinders" categories were, in fact, things that impeded this process of achieving clarity and thus hindered the resolution of the tensions. "Lack of Understanding and Support from Others," "My Own Disruptive Reactions," dealing with "Antagonistic Beliefs and Biases," "Not Knowing," and 141 "Legal Concerns" are all factors that can get in the way of moving forward with growth producing activities. There are sacred and secular elements in many of these categories, some of which have been discussed earlier in this chapter and the reader is referred back for a discussion of the categories involving support and spiritual coping. The categories of "acquiring knowledge" and "not knowing" also addressed the importance of both religious and secular knowledge and the need to integrate these in order to deal with the tensions. There appeared, for most participants, to be a conscious attempt to filter what they were learning learned through the lens of their Christian worldview. A few, who attended Christian universities, spoke of the benefit of programs that explicitly integrated theology and psychology. In these programs they were able to gain knowledge about including Christian beliefs and practices in both the theory and practice of psychology. Others studied theology independently of psychology training or read books from a Christian perspective and noted that these avenues provided a greater amplification and understanding of the issues surrounding the tensions. Although the majority of the incidents in both the knowing and not knowing categories pertained to religious knowledge, secular education and training was valued by all, at least to the extent that all had trained in the science and practice of psychology, in whatever setting this occurred. Secular programs were criticized only to the extent that they did not allow freedom to explore and integrate religious values. Training in professional ethics was particularly helpful for some in understanding the scope of moral behaviour. Several people spoke about the 142 universality of truth, whether found in the study of psychology or theology. Participant #1 summarized this belief: "all truth is God's truth no matter where it's found." This speaks of the need to integrate all knowledge, whether from secular or sacred sources, which was a process that these psychologists appeared committed to. The last stage in the process of resolving tensions was achieving clarity. Many participants spoke of finally being clear on their beliefs or their role in the therapeutic relationship, which was reflected in the categories "Clarifying Goals and Roles," and "Formulating Beliefs & Commitments." Some of the categories demonstrate this clarity in that participants established certain behaviours or attitudes towards their clients. They talked about "Using Self-disclosure to Facilitate Client Empowerment," "Promoting Client Choice," and coming to the point of "Accepting People" for who they are rather than getting too focussed on behaviours. For most this involved a belief in client autonomy, choice, or personal responsibility and the psychologist's role was not to "parentify" the relationship with directives about right and wrong behaviour, but rather to allow the client freedom to choose. These are beliefs that are consistent with mainstream psychology's perspective and values. However, for many of these participants, the rationale for arriving at particular beliefs derived from a religious perspective. Some talked about a faith-based framework of beliefs, being solid in their spirituality, or beliefs based on Christian morals. Others reported being influenced by a Christian perspective on some issues, such as the etiology of homosexuality, the need to deal with sin, or the doctrine of free will. Several people noted that they had come to the conclusion 143 that it is not their role to evangelize or proselytize clients, even though for some evangelical Christians this is one of the foundations of religious practice. A religious-based rationale also held true for many of the incidents in the categories of "Promoting Client Choice," and "Accepting People." Many participants noted the importance of promoting personal choice as a value sanctioned by God. Others talked about following a higher Christian value (modeled by Jesus and other Christian leaders) of accepting people as valuable human beings, rather than focusing on behaviours. Most of the incidents in the category of "Using Self-disclosure" involved sharing their religious values or bias with clients, although the reason for doing this appeared to based on both religious and professional values of promoting client choice or client autonomy. The importance of religious values was apparent throughout the process of resolving tensions. However, in many areas these religious values appeared to be well integrated with professional values. The process largely resulted in attitudes and behaviours consistent with those promoted by ethics codes, such as respect for individuals and promoting client autonomy. It appears that many came to the conclusion that adherence to Christian values and ethical practice did not clash as much as they originally perceived when they first experienced the tensions. For example, the issue of dealing with a client engaged in a same-sex relationship seemed, for many, to shift from focussing on the behaviour to focussing on the person, that is, learning to hold the person in such high regard that the behaviour became secondary. A few of the participants found particular client behaviours (e.g., engaging in extra-marital sexual activity) uncomfortable to work with but 144 expressed a desire not to coerce clients to adopt their religious views. They remained true to both religious and professional values by disclosing to clients their values and/or referring them to other psychologists. In this, it appears that the professional value of promoting client autonomy surpasses other considerations. Values' conflicts The relevance of values' conflicts in psychology has been addressed in the literature on ethical decision-making, values clarification, and cognitive dissonance theory. Each of these modes of dealing with values' conflicts is a process with some similarities to the process-oriented interpretation described above in which the religious values of participants were instrumental in both defining and resolving the values' conflicts. This section will explore these various methods of dealing with conflicting values, commenting on how they relate to the results of this study, especially in regards to inclusion of sacred as well as secular approaches and values. Ethical decision-making According to Kitchener (1984), ethical decision-making relies on critical thinking rather than intuition or "gut feelings" and the steps in this cognitive process are clearly laid out. None of the participants in this study explicitly related using this method of processing to deal with the ethical tensions they were experiencing. However, the interview questions did not specifically address the use of an ethical 145 decision-making model and it is possible that elements of this process were used. Another possibility as to why traditional ethical decision-making models were not mentioned in these results fits with Betan's critique (1997), in which he suggests that these models do not fully describe the day-to-day reality clinicians face in making moral decisions. Betan contends that the emphasis on rational decision-making comes out of a positivist tradition that assumes "an epistemological truth unaffected by context, person, or both" (p. 352). He proposes a hermeneutic model that builds on the principle approach that the interpretation of these principles comes out of the context of one's personal and cultural values. The participants in this study approached ethical decisions or tensions considering their personal moral (religious) values, and the cultural values of both professional and religious traditions to which they belong. Betan's model emphasizes the need for therapists initially to recognize and tolerate ambiguity and conflict in responsibilities, loyalties, and compassions. The participants in this study were able to identify some of these ambiguities by articulating the values' tensions they experienced. The next step in Betan's approach is to help therapists increase awareness of moral values and competing demands that may arise in these tension-producing situations. Again, participants in this study were able to identify the values (both personal and professional) that contributed to the tensions they described. The third step in this model is to help therapists become more facile in the process of making sound decisions based on awareness of these competing values and the need to benefit other persons. Betan notes, "ethical development must be an evolving and deepening process of 146 elucidating the underlying values that determine one's subjective experience and appraisal of difficult, conflictual, ambiguous situations that naturally arise in psychotherapy" (p.361). Betan does not relate specifically to religious values or religiously based interventions, both of which were apparent throughout this study as participants spoke of grappling with value issues in the effort to integrate religious and professional values. There is some evidence in this study to support Cottone's (2001) social constructivism model of ethical decision-making. Cottone argues that decision-making is a social rather than a psychological process in which decisions always involve interactions with other individuals, that is, they are socially compelled based on socially constructed consensus. Professional ethics codes reflect consensualities as to what is appropriate practice. The other major group that embodies different systems of thought and values for these participants is the religious community to which they belong. An example that several participants mentioned in which they faced a conflict of consensualities resistant to easy negotiation was the issue of treating gay or lesbian clients. Professional associations present a very different consensus from that of many religious communities. Participants described feeling "caught" between these two cultures. A significant way of dealing with this tension was to consult with others. Participants talked with supervisors, peers, other Christians, family members, and friends in their effort to come to a new consensus. Although Cottone (2001) did not mention prayer or communion with God, this type of interaction appeared to be essential for the religiously oriented psychologists in this study. 147 Meara, Schmidt, and Day (1996) highlighted the need to consider virtue ethics, which focus on character traits, in the area of ethical theory and ethical decision-making. These authors define four virtues that they see are important for professional psychologists: prudence, integrity, respectfulness, and benevolence. Most religions, including Christianity, also focus on virtuous character. Sandage and Worthington (1997), relating to Christian therapists, noted their agreement with Meara, Schmidt, and Day (1996) that ethics must go beyond the realm of principles and that ethical decisions arise from a person's character or virtue. "Christians have much more than just a set of rules to follow. Christ offers us a person to pattern ourselves after" (p. 121). The primary Christian virtues of faith working through love and humility are embodied in the person of Jesus Christ (God incarnate). All participants noted that their faith in God was in some way helpful in resolving ethical tensions. They looked to God for guidance and for answers and to Jesus as a role model demonstrating how to live out faith in love. One participant noted the importance of humility in looking at ethical issues. It appears that virtuous character, for many of these participants, begins with conceptions of God. The question "who does God want me to be"? is more relevant than "who do I want to be?" Meara, Schmidt, and Day did not mention this religious source of virtue, although it appears that all of the participants in this study construct professional virtue from this divine starting point. Overall, there appears to be a lack of consideration for religious values in the formulation of ethical decision-making theory. One exception is the work of Shweder, Much, Mahapatra, and Park (1997) who described ethics in three moral 148 domains: ethics of autonomy, ethics of community, and ethics of divinity. Ethics of autonomy is a harm-based morality suggesting that people have the right to do what they want provided they do not harm others. This is the most common value orientation embraced by mental health organizations (Rosik, 2003a). Ethics of community focuses on respect, duty, and the integrity and proper state of the social order. Ethics of divinity is based on the assumption of a universal moral order grounded in religious values. Jensen (1998) found that members of a conservative Christian religious group predominantly used ethics of divinity when discussing issues of suicide, divorce, and abortion. Rosik (2003b) noted that these moral epistemologies result in very different conclusions in the area of sexual reorientation therapies. There is evidence from the present study that moral assumptions do impact at least some areas of clinical practice (e.g., dealing with abortion, divorce, and dual relationships) and these moral differences must be examined and accounted for in the process of ethical decision-making. The importance these psychologists placed on Christian values also supports the idea that religious values be included in the formulation of ethical theory. Values clarification There does appear to be some use of a values clarification process for some of the participants. Kinnier (1995) has reconceptualized the idea of values clarification to revitalize the process and make it more useful as a tool in understanding values conflicts. Formerly, values clarification addressed values one 149 at a time in a fairly abstract setting. Kinnier suggests that this process is more useful in resolving specific conflicts in the context in which they occur, using strategies that are relevant for both the person and the situation. He notes that a person can hold an unlimited number of opposing value positions and, for each of these positions, tries to construct philosophical positions that attempt to resolve the conflict. The person could be assessed to be "anywhere along a continuum that extends from 'highly conflicted' to 'resolved.'" The process Kinnier (1995) suggests for facilitating intrapersonal values conflict resolution involves many strategies that participants in this study used. The strategies include defining the conflict clearly, gathering information systematically, emotional focusing, life review, incubation (includes things like meditation), and personal rituals. These strategies have some overlap with the categories developed in this study: Acquiring Knowledge and Training, Managing Amount of Engagement, Engaging in a Process of Self-reflection, Engaging in Spiritual Disciplines, and Following God's Teaching. Kinnier does not specifically address spiritual issues, nor does he appear to recognize the importance of religiosity in making values choices for many people. However, the process of values clarification outlined above lends itself well to including the sacred and this reformulation holds promise as a method to help religiously oriented people identify values conflicts and structure a process of resolution. Cognitive Dissonance Cognitive dissonance is an unpleasant feeling that arises when a person 150 becomes aware that two related cognitions are mutually inconsistent or when he/she feels responsible for negative events or outcomes (Baron, Byrd, & Watson, 1998). This dissonance motivates individuals to change something in their attitudes or behaviour to reduce the discomfort. The strength of dissonant cognitions is affected by two factors: the number of dissonant beliefs, and the importance attached to each belief. Reducing the importance of the conflicting beliefs, acquiring new information that may change the balance, or changing the conflicting attitude or behavior can eliminate dissonance. Many of the tensions that the psychologists identified in this study are likely to produce some measure of cognitive dissonance. Participants were able to describe conflicting ideas or values that would likely produce some dissonance. The conflict in values and resulting cognitive dissonance may have been increased for these participants because of the importance they place on their religious beliefs and because the profession takes such a strong stand in the ethics codes and underlying assumptions on some issues. The activities described in some of the categories fit with the three mechanisms noted above to reduce dissonance. Developing clarity about beliefs and roles in therapy can help to minimize the importance of conflicting beliefs or behaviours. Both self-reflection and increasing knowledge helped participants to explore issues more fully and provided clarity, which sometimes led to changing a previously held belief or behaviour. For example, the initial reaction of some participants was that they could not work with clients engaged in behaviours such as same sex relationships because they believed that this behaviour was wrong. 151 After acquiring more knowledge and reflecting on the issue, some came to the conclusion that the behaviour was less important than demonstrating love and acceptance for a client. Thus, the importance of one religious value took precedence over another. Cognitive dissonance theory appears to apply to the process of resolving tensions described by the psychologists in this study. This theory encompasses both the secular and the sacred elements of conflicting values as it applies equally well to any conflict that produces cognitions that are mutually inconsistent. Summary All of the participants in this study affirmed the centrality of a religious worldview and spiritual practices in their approach to life in general and more specifically to values conflicts. Many of the helping and hindering incidents identified in dealing with the tensions related to religious factors, both directly and indirectly. When faced with tensions between sacred and secular values, participants appeared to go through a process of resolution that started with awareness and concluded with more clarity on a particular issue. Many of the factors that helped them achieve this clarity, and thus reduce tension, included religious beliefs, interventions, and support from others who shared their Christian worldview, demonstrating the importance of the sacred in their lives. However, the secular (including the study of psychology and non religious interventions) was not discounted. A number of the critical incidents related to non-152 religious factors that helped or hindered in resolving the tension. These participants appeared to be committed to integrating Christian and professional moral values. Theories pertaining to the resolution of values conflicts such as ethical decision-making and values clarification have traditionally left out any reference to religious values. Results from this study support the premise that consideration should be given to incorporating the sacred into these markedly secular theories. Limitations of the Study The nature of qualitative research is that it is exploratory and generalizability is not the intent. In this study, the sample size was small, there was no attempt at randomization, and the selection of participants occurred within a fairly narrow definition of "Christian." Tjeltveit (1997) noted that some very conservative Christian mental health professionals would assert, "Christians should not be conformed to the world" (p. 27) and therefore would not likely join a professional association where allegiance would be divided. The sample in this study did not include any individuals in this category, as one of the criteria for inclusion was registration as a licensed psychologist. This "non-conforming" group likely would have much to say about professional ethics codes and experience either a great deal less tension because they do not accept the premise of allegiance to a secular body, or more tension if they did fall under the jurisdiction of a secular professional association with an ethics code. On the other end of the continuum are Christians 153 who hold more liberal views than those in this sample and would not identify themselves as "evangelical." This is a group that could have a different experience of tension between religious and professional values and would likely experience less tension. Even within the community of evangelical Christians there is considerable diversity in theological beliefs and religious practices. Evangelicals could range on their own continuum from more liberal thinkers to extremely conservative. The participants in this study likely represent a subgroup of evangelical Christians in the middle of this continuum and therefore may not be representative of all who would identify themselves as "evangelical" Christian psychologists. Many counsellors and therapists are not registered psychologists. Several counsellors expressed a desire to participate in the study but were not accepted because they did not fit the criteria of registration as a psychologist. There are many counsellors who identify themselves as Christian and including them could add a dimension to the findings that was not captured in this study. All of these factors serve to limit the appropriateness of generalizing the results to a larger population. However, the expert validation did provide some support for the relevance of these findings among a larger group of Christian psychologists. Second, the research was based on self-reports by the participants. The incidents were not directly observed and therefore the veracity of the results relies on the testimony of the participants. Self-reports are limited to the issues people remember during the interview or during their reading of the results. Some of the incidents that participants discussed involve recollections from past events and 154 experiences. This may have led to the exclusion of some events being reported. Flanagan (1954) addressed this limitation in his report of employees at General Motors in which he found that adequate data could be provided from recall during interviews. Implications for Theory and Practice The connection between therapist values and ethics is widely recognized and discussed in the psychological and counselling literature. Psychologists and counsellors are encouraged to consider the impact of their values on clients and the therapeutic process, especially as this relates to the implications for ethical practice. Therapists with any strong values may be particularly prone to imposing their values on clients and constricting client autonomy. Some writers and researchers have made inferences about the conflict between a therapist's personal values and professional ethics (Chapelle, 2000; Smith, McGuire, Abbott, & Blair, 1991) and this study has provided more information about the conflicts some psychologists experience. The results of this study confirm the importance of religious values in the development of ethical practice for some Christian psychologists. To date, ethical theory has not adequately addressed this aspect of value orientation. Given that religious beliefs are a major factor in moral choices for many people, it would be expedient to re-examine ethical theory and the ethical decision-making process within psychological practice and incorporate relevant spiritual or religious factors. A 155 starting point could be the work of Shweder, Much, Mahapatra, and Park (1997), who include an ethics of divinity in the conception of morality and moral decisions. The inclusion of a spiritual element also has implications for training in ethical practice. Religious values are a vital component in the negotiation of moral dilemmas for many counsellors and psychologists. There is a need to create a space for open discussion of religious values within both counselling and psychology programs. Hopefully, this will contribute to what Jones (1994) describes as a "dialogical relationship" between psychology and religion, enriching our understanding of both. This research has highlighted some of the tension areas that do exist for Christian psychologists and has provided some insights and suggestions for resolving these tensions. This is an area that has been largely ignored in secular training programs. The results of this study may provide a starting point for discussion and increase understanding on the part of both instructors and students about the importance of examining these issues. It is noteworthy that the need for support was the most commonly endorsed item in the dealing with these value tensions. Several of the participants in this study noted that their values regarding some issues, e.g., homosexual behaviour, are not the values held by mainstream psychology and felt unfairly judged for holding a more conservative value position. Training programs have the opportunity to be a major source of support if they are willing to enter into this realm of religious values and help students explore the opposing value positions in these areas. This research is specific to psychologists who practice from an evangelical 156 Christian perspective and who acknowledge tension between conflicting values. All of these participants identified themselves as pursuing an integrationist perspective, that is, an effort to integrate the knowledge and values of religious faith with those of psychological theory and practice. It is likely that this willingness and desire to blend two worldviews makes one more vulnerable to values tension than a psychologist who refuses to "mix" allegiances by joining a professional association or one who tries to separate their religious self from their professional self. Acknowledging and normalizing these struggles in training programs could encourage people on both ends of this continuum to explore more fully the impact of values on ethical practice. There also could be implications from this study for other psychologists, counsellors, or therapists who hold any strong values, whether in the broader realm of the spiritual or in social and political arenas such as those who hold feminist ideals or are proponents of gay rights. It is important to recognize that these personal values enter into the therapeutic relationship and can impact ethical practice. If the implication of these values is not explored, there is a greater likelihood of unknowingly bringing them into the therapeutic realm in a manner that compromises or limits client autonomy. Many of the ways the psychologists in this study used to deal with value tensions could be applicable to people with differing value tensions. 157 Implications for Counselling Psychology This research has implications for the field of Counselling Psychology in the realm of ethics and values and also in the area of spirituality and religion. Ethical practice is a primary concern for Counselling Psychologists and is generally governed by professional ethics codes. The value-laden nature of therapy is well recognized and it is virtually impossible for therapists to avoid communicating their values, to some degree, to their clients. Less well understood is how these values affect ethical practice and the focus of this research helped to illuminate one aspect of this issue - the conflict between personal and professional values. There have been reports in the literature of conflicts between personal and professional values (Chapelle, 2000; Smith, McGuire, Abbott, & Blair, 1991) but this is an area that has not been adequately explored. Ethics codes are based on consensus values of professional groups (Bersoff, 1995) but give little guidance in dealing with conflicts between professional values and personal, moral values. This research contributes to our understanding of values and ethics by revealing some of the conflicts or tension points that can occur between professional and personal values. It also elucidates factors that can help and hinder in resolving these tensions. One of the key ways of dealing with value tensions for these participants was finding support in being able to voice and process these tensions. Some found support from clinical supervisors, teachers, and colleagues who provided a forum for open discussion of the value conflicts, advice, affirmation, and reassurance that they were not alone in their struggle. It is likely that others who practice within the field of Counselling Psychology 158 experience value tensions. I believe that this research points to the advantage of providing a supportive environment for students-in-training, for supervisees, and for peers in which there is an openness to discuss value tensions. This support could help with the identification and resolution of conflicts between competing values. Consultation and supervision in the area of value conflicts could help prevent the likelihood of personal values impeding ethical practice. This study also documents that religious beliefs are a major source of values for these participants, and that those values are relevant to their practice. All of the psychologists in this study spoke of the centrality of religious beliefs and practices in their general worldview and approach to psychological practice. This substantiates Alan Bergin's (1980) premise that psychology be expanded to include and integrate religious values in theory and practice. Stanton Jones (1994) also promoted the integration of religion and the science of psychology. He suggested a dialogical relationship between these two domains; that is, one in which both religion and science must be open to the other, engage in constructive dialogue, and be prepared to change. The participants in this study appeared to be committed to the integration of their religious and secular beliefs and values, thus engaging in a dialogical relationship. Others within the field of Counselling Psychology could benefit from the example of these psychologists in their openness to explore, dialogue, and struggle over conflicting values and to be open to the influence of psychology on their religious values and vice versa. The field of Counselling Psychology has begun to embrace the significance 159 of religion and spirituality in many people's lives. This is reflected in the inclusion of religion as one of the areas of diversity recognized in ethics codes that requires training and supervision to ensure professional competence and do away with discriminatory practices. The findings of this research may provide some insights that will aid the integration of religious values into Counselling Psychology theory and practice. The tensions that these psychologists described involved conflicts between religious moral values and values of professional practice. The participants identified such things as struggling to integrate Christian and secular psychology's worldviews, integrating religious beliefs and practices into psychological practice, and dealing with clients who were engaged in behaviours that are generally proscribed in their religious tradition. Many of the factors that helped them resolve these tensions also had some religious association. These included finding support from other Christians, attending Christian universities, reading Christian books (including the Bible), following God's teaching and modelling, and engaging in spiritual practices, such as prayer, for guidance. Although these results cannot be generalized to other religious groups or even to all Christians, they do indicate that religious values are foundational in both perceiving and resolving ethical tensions for some psychologists. More than 20 years have passed since Bergin's (1980) call for the integration of religious values in psychology. Almost ten years ago, Jones' (1994) call for a dialogical relationship provided a thoughtful description of how this integration can be pursued, particularly in noting that both groups need to be willing to change. I 160 view the current research as one step in pursuing that dialogue, and promoting change, within Counselling Psychology. I also believe that psychologists concerned with ethical theory and development of ethics codes can learn from the experience of practitioners such as those who participated in this research. These evangelical psychologists are currently engaged in the type of dialogue that Bergin and Jones have recommended, but they are doing so as an internal dialogue. It is my hope that their experience, and this research, can create a space for more public and professional dialogue on the importance of religious values for clients and practitioners. Future Research This study is a starting point in exploring the impact of religious values on ethical practice. The participants described concrete areas in which they experience these value tensions. The categories of factors that helped and hindered in the resolution of these tensions received support as valid, using several methods of validity checks. One of the expert raters did suggest that the validity of the categories would be much stronger if they were derived from more participants and analyzed with factor analysis. This was outside the limits of the CIT method used but would be helpful to pursue in future research, using the results of this study to formulate research hypotheses. This research focused only on the effect of Christian values on ethical practice. It would be interesting to explore the tensions experienced by other 161 religious groups, particularly those who hold strong moral values. It would also be intriguing to study other non-religious groups who likely hold strong value positions, such as feminist or gay therapists. There were only four women who participated in this study. The numbers were too small to explore any gender differences between participants. However, it could be informative to ascertain whether women handle values tensions any differently than men. Although not the focus of this study, it was interesting to talk with three psychologists who reported that they do not experience tensions between their personal and professional values. Collecting data from these three participants was serendipitous, but there were too few to attempt any comparison. An in depth analysis of the differences between these two groups could be beneficial in shedding light on how tensions are experienced and perhaps enlarge on the results of this study as to what can help in avoiding or dealing with these tensions. The process of resolving tensions was discussed earlier in this chapter. This is another area that would be interesting to study further. This could be approached using either a constructivist/narrative approach to generate participants' stories or a longitudinal study that could track the process during various stages of psychology training and clinical practice. An Addendum: The Process of Reflexivity Reflexivity is the process of critical reflection on the ways in which a 162 researcher's position, personality, background, and assumptions affect the research process (Jones, 1997). In this section I will present some reflections on my process in this research to help readers understand more fully the impact of researcher on the research and vice versa. In qualitative research, the person of the researcher, (e.g., the worldview through which data is collected and analyzed, curiosity, ability to form relationships, and motives for carrying out the study) has significant bearing on the research (Sword, 1999). A qualitative researcher is part of the process rather than an external observer (Grafanaki, 1996). These statements reflect my beliefs that no research is free of researcher biases and assumptions, that all research has a subjective component, and that acknowledging these facts increases legitimacy. This also increases our understanding of the research findings, thus increasing the credibility of the product and strengthening one's credibility as a researcher. I undertook this research because of my own struggles in working through areas of tension between my own religious values and the values espoused by ethics codes. How could I be "true" to my own beliefs and values and work effectively and ethically with clients who held quite different assumptions and moral beliefs? Throughout the research process, I engaged in a process of self-refection aided by journalling and discussions with my research supervisor and others familiar with my research. A possible impediment in conducting this research is that I am an "insider" (in this case, that there is a commonality in many religious beliefs and attitudes between myself and the participants). From this insider view, I am more likely to make assumptions about what participants mean in their accounts of tensions and 163 incidents (Romans, 1993). I took care to prevent this from occurring and found myself saying to participants on a regular basis: "I just want to make sure that I understand what you are saying and am not making assumptions." It was important to be aware of my reactions to the participants throughout the process. When I felt a sense of resonance, I could feel my excitement mounting and I would find myself thinking "this is really good stuff!" I had to be careful not to allow this enthusiasm to colour my findings by accentuating incidents that fit my beliefs. Conversely, there were times when I found myself frustrated with the responses of some participants. I came to recognize my own bias in regards to dogmatic or black-and-white thinking. A participant making reference to a particular behaviour being "sinful" in a way that prohibited any discussion of context or circumstances (e.g., referring to a Biblical position of homosexual behaviour as wrong or sinful, with no acknowledgement of our limited understanding of its etiology) would leave me feeling disturbed and sometimes irritated. My initial reaction was to leave out these references because I did not want any readers to discount my research on the basis of it being about "narrow-minded religious fanatics." In becoming aware of my own biases I was able to present my findings more authentically. Another issue that I became aware of was the power differential between the participants and myself. Many researchers write about the inequality of power between researcher and participant with the concern being that the researcher holds more power (Jones, 1997). In contrast, at times I found myself in a position of feeling disadvantaged because the participants were not really my peers but 164 established practitioners, whereas I am "only" a student. I was fearful that any feelings of inadequacy might limit my ability to use probing questions in sensitive areas. As I became aware of these feelings, I was able to work through my own anxieties and establish myself as a credible, competent researcher. Maintaining confidentiality was a concern in choosing and interviewing participants. The Christian community, in many ways, is quite small and close-knit. Some of the contacts I made were people referred by other Christian psychologists. I had to be very careful about how I approached some of the participants. Several of the participants were gathered at a Christian conference in San Diego. There was awareness among conference attendees that I was doing this research and was looking for participants. A couple of people who agreed to be interviewed were not concerned about keeping their identities hidden and even suggested that we conduct the interview at the poolside in plain view of others. However, not everyone interviewed was as open about his or her participation and there were a couple of difficult moments when I was asked who I had interviewed and had to say that I could not tell. Jones (1997) speaks to the issue of "cleaning up the text" (p. 350). Some of my participants expressed concern about how they sounded in the transcript in regards to their 'ahs' and 'uhms' and false starts, which could be negatively perceived by anyone reading the text in the research write up. The dilemma for me, as Jones describes, was to provide a totally accurate rendition of the conversation. When asked to clean up the quotes, I decided that this was a reasonable request as these were their words and they had a right to modify them. In the context of this 165 kind of study and method, I did not feel that this request would negatively affect my interpretive goals. One of the difficulties I experienced during the interviews was to maintain a predominantly unidirectional relationship with study participants. Very often, especially if I found I was in agreement with what they were saying, I wanted to enter into a dialogue about particular issues and share my own thoughts and experiences. I avoided doing this as I felt it would move me away from my role as researcher, which in the CIT is to listen and stay focused on the participants' incidents. At some point in the future, after the study is completed, I hope to have the opportunity to engage in discussion with some of the participants on some of the issues they revealed. Overall, I recognize that my personal self - my biases, values, and personhood - had an impact on both the data collection and the analysis of the findings. However, I also believe that my background and familiarity with the issues and the literature helped me to establish rapport during the interviews and enhanced my ability to interpret the data. I do not believe that my interpretation and categorization of incidents is the only legitimate account of the data; however I do think that the analysis I rendered is legitimate and is confirmed by the procedures conducted to determine validity. I gained much from doing this study. It was exciting to speak with practitioners who have been thinking about these issues for many years and have come to some resolution of the tensions. I had the opportunity to hear many different perspectives on some of these contentious issues and this helped to clarify 166 my own beliefs and values. I had some initial concerns that Christian psychologists would be fairly narrow in their thinking and was delighted at the openness and depth of consideration that most participants gave to these issues. 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Journal of Psychology and Theology, 13, 29-41. 185 Appendix A - Letter to Prospective Participants Date Dear : My name is Kathleen Irvine and I am investigating the tension therapists feel between their Christian moral values and the values of professional associations and ethics codes. This research is part of my doctoral work in Counselling Psychology at the University of British Columbia in Vancouver, BC. This research is being conducted to determine the factors that help or hinder Christian psychologists work toward resolution of the tension between their Christian moral values and the values of professional psychological associations. I am looking for Christians who are registered psychologists in clinical practice to participate in this study. Participants must be willing to: 1. agree to the statement of faith of the Christian Association for Psychological Studies: belief in God the Father, who creates and sustains us; Jesus Christ, the Son, who redeems and rules us; and the Holy Spirit, who guides us personally through God's inspired Word, the Bible, our infallible guide of faith and conduct, and through the communion of Christians. 2. participate in two tape-recorded interviews (each would last 60 - 90 minutes), the place and time to be arranged at your convenience. 3. discuss the tensions and conflicts you have felt between your Christian moral values and those of your professional association's ethical guidelines (confidentiality will be maintained by disguising the identity of participants). Participants will be asked the question: "Think back to a time when you felt tension between your Christian moral values and the values that are embraced by your professional psychological association (usually via the association's code of ethics). What helps/helped you in the process of working toward resolution of this tension? What hinders/hindered this process?" Your involvement in this study would be voluntary and you would be free to withdraw at any time. Your identity will always be kept confidential. The total time commitment for both interviews is expected to be 2 - 3 hours. Each interview will be audio taped and, if necessary, the second interview will be conducted by telephone. This research is being conducted under the supervision of Dr. Beth Haverkamp Department of Educational and Counselling Psychology and Special Education 186 will be available to recommend referral sources. It is also hoped that this information will help other therapists struggling with similar issues. Confidentiality Any information resulting from this research will be kept strictly confidential. Any direct quotes from participants that are used in the final report will have any identifying details changed or removed. If a lengthy quote is to be used, the participant will be asked for permission. Upon signing the informed consent you will be given a code name of your choosing to ensure maintenance of confidentiality. This code name is the only way you could be individually identified in the research report. All data, including audiotapes, paper files, and computer files, will be kept in a secure location in my home office. No one but myself will know participants' identities and only myself and my research committee members will have access to the data. Upon completion of the study, the audiotapes will be erased. Paper and computer files, with any identifying data removed, will be kept for five years and then they will be destroyed. If you have any questions or concerns at any time during the study, you are encouraged to contact Dr. Haverkamp or Kathleen Irvine at the above numbers. You may also contact (Dr. RD Spratley, Director, Office of Research Services, at 822-8595) if you have any concerns about your treatment as a research participant. You will be informed of any significant information that may concern you. I have read the above information and I have had an opportunity to ask questions to ensure I understand what my participation involves. I freely consent to participation in this study and acknowledge receipt of a copy of this consent form. Signature of Participant Date Signature of Researcher Signature of Witness Thank you for your willingness to participate in this study. 189 Appendix C - Demographic Information Age Gender Education Psychology training Number of years of clinical experience Ethics training Work setting (secular, identified "Christian" practice) Geographic location (urban, rural) Denominational background 190 Appendix D - Interview Questions Think back to a time when you felt tension between your Christian moral values and the values that are embraced by your professional psychological association (usually via the association's code of ethics). 1. Describe the situation including the experience of the tension and the difficult choices perceived. 2. What Christian value was at stake here? 3. What professional value was involved? 4. What events or factors help/helped you in the process of working toward resolution of this tension? 5. How does/did it help? 6. What events or factors hinder/hindered this process? 7. How does/did it hinder? 8. What other things helped or hindered in this situation? 9. Are there any other situations in which you experienced tension between personal and professional values? 10. Closing question: Identity as a Christian Psychologist If you were to consider the four positions regarding the relationship between psychology and Christianity as outlined by Kirwan (1984), which one would best describe your beliefs? a) un-Christian view - human reason is the ultimate source of truth and religion has nothing to offer b) spiritualized view - all emotional disturbances are spiritual problems c) parallel view - little overlap between Christianity and psychology d) integrated view - truths of psychology and the Bible can be integrated in a harmonious fashion 191 Appendix F - Recruitment Letter - Conference Participants Date Dear Conference Participant: My name is Kathleen Irvine and I am investigating the tension therapists feel between their Christian moral values and the values of professional associations and ethics codes. This research is part of my doctoral work in Counselling Psychology at the University of British Columbia in Vancouver, BC. This research is being conducted to determine the factors that help or hinder Christian psychologists work toward resolution of the tension between their Christian moral values and the values of professional psychological associations. I am looking for self-identified Christians who are registered psychologists (PhD) with at least five years experience in clinical practice to participate in this study. Participants must be willing to: < agree to the statement of faith of the Christian Association for Psychological Studies: belief in God the Father, who creates and sustains us; Jesus Christ, the Son, who redeems and rules us; and the Holy Spirit, who guides us personally through God's inspired Word, the Bible, our infallible guide of faith and conduct, and through the communion of Christians. < participate in two tape-recorded interviews (each would last 60 - 90 minutes), the place and time to be arranged at your convenience. < discuss the tensions and conflicts you have felt between your Christian moral values and those of your professional association's ethical guidelines (confidentiality will be maintained by disguising the identity of participants). Participants will be asked to discuss the tension they have experienced between their Christian moral values and the values that are embraced by the professional psychological association (usually via the association's code of ethics). They will then be asked to talk about the factors that helped or hindered them in dealing with this tension. 193 Appendix G - Letter to Expert Validators Date Dear , A s part of the validation procedures for my doctoral dissertation (Evangelical Christian Psychologists' Religious Values and Ethical Practice), I would like to have your expertise in assessing the relevance and usefulness of the attached categories. I'll give you some background on the method I'm using and then some particulars on my study. I am using the Critical Incident Technique (CIT), a well-established qualitative method that was developed by John Flanagan (1954) during World War II to identify criteria for effective pilot performance. Flanagan originally described CIT as . . . a set of procedures for collecting direct observations of human behavior in such a way as to facilitate their potential usefulness in solving practical problems and developing broad psychological principles (p. 327). CIT focuses on incidents that are critical, that is events that are explicitly observed or experienced that directly affected the outcome for the phenomenon being studied (Woolsey, 1986). Participants are chosen based on their ability to have observed or experienced things that facilitated or hindered phenomenon relevant to the research question. After completing the interviews, the critical incidents are identified and grouped according to thematic categories that provide a conceptual map of things that help or hinder the process being studied. After the war, Flanagan further developed the technique and described its use for research in industry, occupational competencies and screening, and psychological constructs (e.g., a functional description of emotional immaturity). For several decades after the 1950's, the CIT fell into disuse because of the field=s emphasis on quantitative methodologies as the standard for scientific studies (Woolsey, 1986). Woolsey encouraged the revival of this technique for counselling research as A a n exploratory method that has been shown to be both reliable and valid in generating a comprehensive and detailed description of a content domains (p.243). This method has subsequently been used in a variety of applied psychological research projects - including many in my department, from both students and faculty. If you would like any further information on this method, I would be happy to send you the articles referenced above. My research question is "What helps or hinders evangelical Christian psychologists deal with the tensions they experience between their Christian moral values and the values of professional, ethical practice?" Below are the categories for review. These categories were constructed through an inductive process, from interviews with 12 participants. Some general demographics of these participants are: • all are registered psychologists (11 at the doctoral level, one MA), from Canada and western US; • all are self-identified as "evangelical" Christians and could endorse the C A P S statement of faith. • clinical experience: 8 - 30 years; • age range: 39 - 66 years; 195 Instructions for Validation Procedure: In my analysis, I have delineated the tensions you talked about and the factors that you mentioned that helped or hindered in dealing with these tensions. You have two documents to read - the first is labelled "Tensions" and the second "Helps and Hinders". A. The first document (Tensions) contains excerpts from the transcript of your interview describing the tensions you experienced. Please look this over and ensure that I have captured the essence of the tension you described. If you wish to add anything to this, feel free to do so. If there are any statements (or parts) that you would rather not have included in my research write up please let me know (although, please remember that your identity will be protected. You are simply participant # - ) . B. The second document (Helps & Hinders) is the main component of my analysis. In this I have picked out excerpts from your transcript, which describe a "helping", or "hindering" incident - that is something that either helped or hindered you deal with the tension you experienced between your Christian moral values and the values of professional practice. I have coded these incidents with a name that I hope captures the essence of the meaning you intended. I have then grouped these incidents into broader categories or themes. I have given you a description of alj the categories and listed your incidents under the category in which I placed them. Please note that vou may have more than one incident in some categories and none in other categories. A s you look through this document, there are several things I am asking you to do: 1. Check for accuracy in the quotes I have chosen and feel free to add anything to the quote to explain it further. 2. Ensure that the code name is appropriate for the content - does it capture the essence of your meaning? 3. Provide feedback on the category that contains each quote. Does the category I put each one in seem to make sense and "fit"? If there are any quotations that do not fit please indicate the category in which you think it should go (if there is one). 4. I have not yet decided which quotes I will be using in the report, but if there are any of your quotes (or parts of quotes) that you would not be comfortable having included in the write up, please mark these. 5. Provide any other feedback you care to! 198 Appendix I - Letter to "Group B" Participants Date Dear — , Thanks so much for agreeing to look over this material and provide comments. Just to refresh your memory, I am investigating the tension therapists feel between their Christian moral values and the values of professional associations and ethics codes. This qualitative research project is part of my doctoral work in Counselling Psychology at the University of British Columbia. This research is being conducted to determine the factors that help or hinder Christian psychologists work toward resolution of the tension between their Christian moral values and the values of professional psychological associations. Although your interview did not fit the criteria for analysis because you don't feel the tensions I was asking about, I think your thoughts on this matter provide a valuable contribution and so I found a way to include it! It will be written as an addendum to the Findings chapter. You will be known simply as Participant #--. Attached is the write-up from my research that pertains specifically to your interview. I have summarized the interview and would like you to read it over and ensure that I am accurate in my reporting and my interpretation. Feel free to make any corrections or additions. If there are any quotes that you would rather not have included in the write-up, let me know. If you have any questions about this process, let me know. The main body of the research writing is going well and I hope to turn in a first draft to my supervisor very soon. If you would like a report of the overall findings let me know and I'll be happy to send it to you. Thanks so much for your help! Kathleen Irvine 199 Appendix J - Group B Participants Demographic Information for Group B Variable Description Average Age Gender Country of residence Education Years experience Work setting Ethics training Primary ethics code Religious affiliation 50 years (range 41 - 60) All male 2 Canada; 1 US All with PhD; 1 obtained graduate training in psychology from a Christian university; 2 hold a divinity or theology degree 19 years (range 11 - 25) All work in urban setting; 1 primarily Christian setting; 2 primarily secular range of settings included private practice, outpatient government clinic; 1 described himself as primarily an academic 2 did graduate course work; 1 had no formal ethics training 2 APA; 1 Provincial 1 Baptist, 1 Lutheran, 1 Evangelical conservative 200 Appendix K - Results from Group B Participants The three participants in Group B reported that they did not experience any tension between their Christian moral values and the values of professional, ethical practice. These interviews were completed but not used in the analysis of factors that help and hinder psychologists in dealing with tension. The focus of the interviews became a questioning of why they did not experience the tension the other 12 participants described. Following is a summary of each interview with these three psychologists, focusing on areas that appear to intersect with the research question. Participant #13 This participant expressed little conflict between his moral values and values of professional practice. I also heard it as ... does the ethics hinder my expression of my moral values or that sort of thing. And I guess I haven't really felt that. I've been somewhat, I think, grateful, for ethical standards, because I think they're pretty helpful, pretty clear, and they don't seem inconsistent with my faith. It seems that they don't battle one another too much or...interesting enough maybe they're more Christian than sometimes our own agendas or whatever. 201 He related that this lack of tension comes from his understanding and approach to the Christian faith. My understanding of the Christian faith and my approach to it is that I am there to assist the patient to discover and to uncover and to explore and that I do not have a completed picture of what God's intent for this particular person is, or what it is they should do, or what they shouldn't do. And so I am very given to the person's own experience of God. So for example, if it was abortion or homosexuality or something like that, I'm not given to a particular value of mine that they must adhere to. My givenness is to God if you will... my Christian value is of a God of such huge magnitude of grace... therefore, I want to be in the moment of discovering that, not in dispensing who gets it and who doesn't. I think I would, like going back to abortion or homosexuality or any of the hot things or divorce, is that I want to be open to this magnificence of grace, not saying you get it and you don't... because I don't know how you are going to experience the grace of God. I don't know how your life is going to unfold in such a way that this unbelievable God, reveals himself to you. I want to be ready and open to that. He spoke of a higher value that guided his practice of therapy. 202 I can have a value of my own, but there's a greater value that supersedes all of them, and that is God, and the grace of God and the love of God, and I just don't have any need to be adjudicating somebody else's life... the area of judgment for me is destruction of relationships...! guess I have this greater value which is, I don't know how your life is to be, I don't know how it was intended, I don't know your journey and I don't know the things that you're going to do to hinder and damage your life like we all do. I do know one thing, that no matter what we do, grace abounds. It will be there and it will lead you on and that whatever we do for some reason is never the end of the story. In fact it could even be the beginning of the story. He went on to say that he uses informed consent to let people know what the therapy he practices is about. Through informed consent I tell people that my work is about character, not necessarily about behaviour, and it is about what it means to live successfully and wonderfully in relationship, and that it's hard work to do that and that that's what we're setting ourselves out. So I think from the beginning they know that I'm not here to simply help them communicate better in a marriage or to solve a behavioural problem or whatever, but that it is about characterological kind of experience. So I don't think there's an ethical dilemma there. 203 This participant noted that his theological training was helpful in formulating his thinking. I know that my theological training was extremely helpful of changing my linear thinking about me and God to a contextual thinking and a community thinking, and that Christ was made manifest in our incarnational moments and that I had to be a waiter and a facilitator of those moments, and if that was to occur that we would both be transformed. And so I am most grateful for my theological foundation that challenged me in that way. He also related that the support of other people, including his family, a friend, professors, his patients, and a Catholic community, was instrumental in helping him to formulate his beliefs. Participant #14 Number 14 reported that he does not experience conflicts between his moral values and values of professional practice: "I don't find a lot of conflicts." He notes that this is probably because he began integrating psychology and theology while in graduate school at a Christian university. Maybe because of the integration position I've taken...That was the paper that I chose to write on for my systematic theology class and so 204 that started to formulate, you write a paper just for the course right...You go back and to your two New Testament profs and say what do you think this means right? They'll tell you from his perspective right. You go back and integrate some more. The integration program starts in the first year. Everyone takes this course. It's an eye opener program. This integration happened because of his willingness to struggle with the issues. You went to [Christian university], supposedly the most liberal of the conservative universities... So I went in there and kept an open mind and realized that what they were doing was very courageous because they're trying to answer very tough questions that most people don't want to answer... So you go there to struggle. That's what they do, go in there to struggle and grapple with this document [Bible] that is written by so many people, over such a long period of time and say what does God want to say... So you do a lot of soul searching, grappling, that starts the process going. From this integration perspective, he has developed a clear belief system that informs his practice with clients. 205 People will come in here broken whether... it's a divorce case, abuse issue and I'm right there with them because there's strong Biblical scriptural support...To be incarnate Christ to be there right, it means through Jesus he attracted the prostitutes and that kind of person. The rich were uncomfortable with this style of things but Jesus always attracted those folks...it's a recognition that people are broken, all broken and for me when they come in here the question is not whether they are broken or not but where is the brokenness? Allowing them to feel that it's okay to come in here with their brokenness... so for me therapy is a sacred task. It's using change agents that God has Himself used to promote change for people towards healing personhood. The Bible has been a major source of information and modelling for him. The Bible is not a book about perfect people teaching imperfect people to live their life right. Thankfully because if you look at the scriptures there are people who struggled with God who felt abandoned by God right, and they become comforting for us because God includes these people as his own... Especially in the book of Psalms. You can look at the book of Psalms from a secular point of view and say, wow; this is clinical notes of a challenged person. 206 Participant #15 Number 15 expressed no concern regarding tension between conflicting values. No, nothing really comes to mind in terms of a real conflict or stress in terms of my values and professional association values. He related this primarily to his clarity about his role. Well you see when I'm hired as a psychologist here; it's been hired to treat psychological needs. I kind of feel I'm not here to deal with spiritual dimension. And in fact if I felt, if I was bringing in spiritual dimensions if I'm talking about them, it would be unethical for me because that's not what my employers hire me for... For me, even for a gay for a Christian, they couldn't change I think it would be between them and Christ. That's where I would direct them and say well this is the problem you've got to direct and solve in your prayers with Christ and this is between you and him. You've got to start working it out there on that level. I certainly wouldn't condemn him. One of his overriding beliefs is that clients have a right to choose their own values and beliefs. 207 We could still have a client who's contemplating divorce but you see I don't impose my Christian values on my clients. They have a right to whatever values they want because I see obviously my clients come from every persuasion from Jehovah Witnesses to whatever Mormons to homosexuals... I may not agree with all of it but I accept that they have a right to have these beliefs. It's not up to me to impose any of my beliefs on them. But they often make the best choices that they can under the circumstances, which is the best choice for them, which would be therapeutic for them... we live in a pluralistic society so maybe what's right for me may not be right for them. Every person has the right to have their own choices so yeah, I get lots of gay clients throughout the years and some of them have problems with social anxiety because of their gayness and their ability to interact because they are worried about other people's reactions, I help them deal with that. That's the presenting problem that they want to work on. It's not a problem for me. Modelling by other Christians has been important in developing a particular attitude of acceptance toward clients. One model was Mother Theresa. Yeah, I think Mother Theresa's prayer, I can't remember it all, but I remember she has it in all the. ...and used to read it every day. Lord help me to see you and the people that come to me for help, as I 208 minister unto them let me minister unto you. I think it was a tremendous philosophy in terms of her helping people. I am sure a lot of people she helped are of course Hindus or Muslims, and that kind of background... I think that's my orientation is to see Christ in everyone that comes to me for help. More along the same philosophy, that everyone here has Christ within them. Another important influence was the writings of a Catholic priest, Henri Nouwen. And you're talking about homosexuality, I don't know if you know Henri Nouwen, well he's a Catholic priest of course that wrote many, many things, "The Prodigal Son" I think which was the most famous...but people don't know he was homosexual. But he was not practicing but what it indicates obviously shows that there's a place for homosexuals within the Christian church and that they can make tremendous contributions. Who are we to judge? I mean he was called to that by God and look how God used him. His writing is so influential both in the Catholic and the Protestant world. Christ's modelling has also been an important influence. Christ loved everybody, prostitutes and sinners and everybody else associated with Him, so if He's my model why wouldn't I be helping all these people and being open and tolerant towards them too. 209 To be a psychologist was seen as a calling from God. I think He's chosen me to be in this role and the work I do everyday is a service to him. That's the way I see it...So helping people everyday, here, to me is a service to Him. Participant #15 also noted that the openness towards spirituality today has created a more supportive environment than he remembered earlier in his career, but he did not think that this affected his basic beliefs about his role and the separation of psychological and spiritual. Probably less hindrances today with the more openness towards spirituality than when I first started practicing because I guess now I have, it's so easy to raise the spiritual dimension with clients and discuss it with them and then refer them and talk about what's therapeutic and not therapeutic, even with colleagues because of the openness. Whereas when I first started practicing that openness wasn't there so I don't know whether, I don't know if that was a big hindrance of any kind, I guess I feel more at ease to doing that today than I did twenty years ago but it was still the same philosophy that I had. I was paid by a secular organization to do psychological counselling. There's always good people in the community that can do good spiritual counselling. 210 


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