Eric Scalise, Ph.D. & Tim Clinton, Ed.D.
Spirituality is mysterious, but real. It has offered countless millions a place of refuge, solace, comfort, hope and a deeper sense of purpose and meaning—especially in times of tragedy or crisis where grief and despair crouch at the doorstep of the soul seeking to rob a person of vitality and life. Although spirituality continues to be an evolving construct among the social sciences, thus far, the research literature generally affirms its profound and dynamic impact on mental health and mental health counseling. Why is it then—in a multicultural and postmodern society—that some practitioners and counselor educators continue to avoid or even disparage this potential client strength when it comes to treatment planning and desired therapeutic outcomes?
Some may remember that in the early days of mental health research, Freud referred to religion as nothing more than a mass neurosis. McMinn et al (2009) report that psychologists do not assess religious and spiritual issues in most cases and do not therefore include them in treatment plans. Thankfully, this important dimension of the human experience is not being completely ignored (Briggs & Rayle, 2005; Young et al, 2007). Dobmeier and Reiner (2012) note that the 2009 standards from the Council for Accreditation of Counseling and related Educational Programs (CACREP) specify some level of spiritualty integration in two of their core curriculum requirements. Religion and spirituality can no longer be simply viewed as an emotional or psychological “crutch,” but for the potential client strengths they consistently represent in the literature.
Certainly world history is replete with examples where organized religious fervor and ideology have been leveraged in shameful ways. However, at its core and within the individual, a person’s spiritual orientation often represents the defining value system from which cognition, affect, behavior and relationship flow. Perhaps the time has come to more fully acknowledge the presence and influence of spirituality, to embrace its utility as a vital clinical resource, and to make a definitive case for faith in mental health care. At a minimum, the conversation needs to unfold within the professional milieu.
Spirituality offers a legitimate framework for an individual’s value/belief system and from which subsequent behavior is then derived. A recent Internet search done in March, 2015 and using the Google search engine, revealed well over 100 million Web pages related to the construct. As an emerging theme, spirituality can signify different things to different people due to its multidimensional nature (Tischler, Biberman, & McKeage, 2002) and yet, is something that most individuals seem to possess as an important component of their human existence (O’Reilly, 2004). One might say that it is an inherent aspect of human nature and involves concepts such as wholeness, restoration, hope, comfort, joy, guidance, and belief in the hereafter. Fairholm (1997) refers to spirituality as, “the essence of who we are, the intangible, life-giving force in self and all people” (pp. 6-7).
In a more practical context, spirituality has been described as a person’s multifaceted system of beliefs, morality, values, and knowledge of right and wrong (Fairholm, 1997; Gall et al., 2005; Sphon, 1997). Bruce (2000) expands this thought further:
Only modest agreement on the definition of spirituality exists. For one Catholic theologian, spirituality is “the way one orients themselves toward the divine.” For a physician at the Harvard Medical School, it is “that which gives meaning to life.” For one social worker, it is “an individual search for meaning, purpose, and values which may or may not include the concept of a God or transcendent being.” For others, to be “spiritual” means to know and to live according to the knowledge that there is more to life than meets the eye. To be “spiritual” means, beyond that, to know and to live according to the knowledge that God is present in us with grace as the principle of personal, interpersonal, social, and even cosmic, transformation. (p. 461)
Webster’s Collegiate Dictionary defines the spirit as the, “soul of man – the intelligent, immaterial and immortal part of human beings” and simply refers to spirituality as the quality of respecting the spirit. For Mitroff and Denton (1999), spirituality is the desire to find ultimate purpose in life and to live accordingly; it is the, “basic feeling of being connected with one’s complete self, others, and the entire universe” (p. 83). Similar views speak of spirituality as representing the ongoing search for meaning and purpose, an appreciation for the deeper things in life, that which constitutes a person’s individual belief system, and an awareness of the presence and divine nature of God.
In theistic terms, spirituality helps define a person’s connection and service to God (Lerner, 2000) and in terms of a lived experience, it provides purposeful relationships, a “joyous and compassionate attitude toward oneself and others” (p. 5). As an expression of religious involvement, Helminiak (2001) views spirituality through the lens of an organized system of beliefs, rituals, and collective traditions. However, another important consideration is recognizing that spirituality is not merely some global, metaphysical, or ethereally vague concept, but directly associated with a person’s specific theological creeds.
Faith Makes a Difference
Many may ask the question: Does faith really matter when it comes to treating and resolving complex psychological problems? Bidwell (2002) coined the term “pneumatraumatology” to describe an array of trauma-related symptoms that impact a person’s sense of spiritual wellbeing. These include feelings of isolation, inadequacy in the face of overwhelming situations, and no concept of permanence in that which is familiar. However, “a healing experience does not require a ‘spiritual master’ to be effective, ethical, or valid. Some may argue that the wounds of the soul are among the most difficult to detect and quantify. Connecting as a human being and offering validation for the experience of pain can provide extraordinary comfort and healing to the distressed spirit” (O’Reilly, 2004, p. 48). It can also lead to greater empowerment and overall fulfillment (Nichols & Hunt, 2011) and improved coping skills related to chronic illness (Narayanasamy, 2004). A vibrant personal faith encounter has proven to increase resilience, coping, and successful treatment for a variety of conditions including, chronic pain (Glover-Graf et al, 2007), poly-substance abuse (Heinz et al, 2007), and comorbidity among trauma survivors (Fallot & Heckman, 2005).
A person’s religious beliefs and practice often serve as a positive source of interpersonal strength. In one study (Gregory et al, 2008), when the religious orientation of a therapist was disclosed at the onset of treatment, clients were significantly more likely to have a desire to work with the mental health professional. Some authors indicate that clients want to include spirituality in their treatment, but preferences are not as well understood (Saenz & Waldo, 2013). However, according to Koenig (2000), merely completing a spiritual history with a client (where faith is valued), yields treatment benefits through the process. In one study of patients who were consecutively hospitalized (Baetz et al, 2002), regular involvement in worship-based activities correlated with lower levels of depression and alcohol abuse. Post and Wade (2014) demonstrated the efficacy of religious practice and spirituality in group therapy outcomes, as did Lietz and Hodge (2013) with substance abuse counseling. Johnson et al (1994) also posit that biblically-oriented psychotherapy has proven to be successful in treating different forms of depression, reducing automatic negative thought patterns, and lowering overall pathology levels in a measureable way. A separate analysis of twenty-four empirical studies drew the same conclusions (Mueller et al, 2001).
The rising trend to pursue and not avoid the integration of spiritual practices in client care appears to be the preferred clinical strategy (Kliewer, 2004). This may be because a growing body of research correlates client spirituality with improved health outcomes (Miller & Thoresen, 2003), as well as the impact on couples therapy (Ripley et al, 2014). In another thorough review of the quantitative research literature on emotional and mental hygiene, Larson (2003) concludes that a patient’s spiritual orientation provides helpful coping mechanisms, enhanced pain management, protection against depression, and reduced risks for both substance abuse and suicide.
There have been numerous community-sample and longitudinal studies that have investigated the impact of religious practice on mortality rates. In a large comprehensive meta-analysis, McCullough et al (2000) reviewed and summarized 42 study samples that evaluated a total of 126,000 people. They found that religious involvement increased life expectancy by 29%. Religious involvement was defined in terms of attendance at services, how personally important participants ranked their faith, and the degree to which participants found strength and/or comfort in their relationship with God. The only other factor in the analysis that remotely approached the efficacy of religious involvement was the lack of obesity. Likewise, within the military community, Parker (2001a, 2001b), first evaluated the Department of Defense’s approach to health promotion policies and then described an integrative model (strongly supported via numerous empirical studies) that included a greater emphases on positive spirituality.
Other research studies have focused exclusively on mental health factors. One study of over 400 chronic patients conducted by Tepper et al (2001), confirmed the causal relationship between the participant’s faith orientation and their symptomology. A significant majority (80%) utilized some form of religious belief or activity to cope with their symptoms on a daily basis, with 65% reporting that their religious practice moderated symptom severity. Nearly half (48%) indicated that their faith became even more relevant whenever symptoms worsened, while 30% stated that this was the most important thing that kept them motivated in treatment. The longer a patient had integrated spiritual coping mechanisms, the lower their symptom levels were in six different categories (obsessive-compulsiveness, interpersonal sensitivity, phobic anxiety, paranoid ideation, psychosis, and total symptomology). The most prevalent coping strategies were prayer (59%), followed by attending religious services (35%), worshipping God (35%), meditation (33%), reading Scriptures (30%), and meeting with a spiritual leader (15%). The researchers noted the general unavailability of trained spiritual leaders and suggested that new models of service provision be developed that better linked the professional community with faith-based counselors/clergy members. These results have been confirmed or replicated in numerous studies related to current treatment modalities as well as posttraumatic growth (Baetz et al, 2002; Fitchett et all, 1997; Kendler et al, 1997; Shaw et al, 2005).
When looking specifically at the issue of depression, McCullough and Larson (1999) examined more than 80 studies conducted over the past 100 years and found that spiritual/religious factors generally accounted for lower rates and reduced symptomology. Individuals who placed high a value on their faith and engaged in religious activities were at a significantly reduced rate across all depressive disorders. Meanwhile, those without any religious or faith-based involvement had a 60% increased risk of suffering from a major depressive episode. Finally, participation in a faith-based community fostered both hope and caring and was seen as an important preventative measure that helped inoculate people from susceptibility to depression.
Another landmark study (Propst et al, 1992) discovered a link between religious beliefs and practices (specifically Christian-oriented), rates of depression, and receiving religiously-oriented cognitive behavioral therapy—which meets the American Psychological Association’s threshold standard as an empirically supported treatment. Participants showed reduced symptoms of post-treatment depression, balanced clinical adjustment, and lowered recidivism with this mode of treatment, especially when they were receiving the modality in what was perceived as a framework that was congruent with their beliefs and practices. Another interesting aspect of this particular study involved two randomized groups (those receiving therapy from caregivers who were religiously oriented and those receiving therapy from caregivers who were not religiously oriented), where both sets of participants still showed significant clinical benefits. The researchers noted that even though a religiously-oriented therapist was certainly important, the greater value appeared to be the actual content of the treatment regimen (i.e., the specific integration of the tenants of their faith). This supports the notion that Christian-informed therapy (with biblically-based content), coupled with pastoral counseling and/or care, demonstrates robust improvement in depression outcomes.
Probably the most negative and destructive aspect of major depression is increased suicide risk. Two national studies, one conducted nearly 40 years ago (Comstock & Partridge, 1972) and another more recently (Nisbet et al, 2000), both demonstrated that non-participation in religious activities increased suicide risk by almost 400%. Koenig and Larson (2001) reviewed a total of 68 studies that addressed the link between suicide and religion and found that in 57 of them (84%), there were lower rates of suicide among those more actively involved in faith-based activities. Causal determinants that helped promote these results included enhanced self-esteem, improved personal accountability, and an increased awareness of responsibility to God. Statistically similar findings can be found in other studies that take into account an expanded age spectrum (Larson & Larson, 2003; Rasic et al, 2001). Given the kind of documented results just described in this section from a treatment perspective, there appears to be tangible value for developing a more comprehensive model that integrates the disciplines of psychology and theology. A key question is where to begin and with what population?
Understanding and Incorporating a Judeo-Christian Paradigm
By in large, the United States remains an overtly spiritual nation, as well as one that leans toward Christianity on the broader religious spectrum. A 2009 Harris poll of 2,303 U.S. adults (18 and older) found that, “82% of adult Americans believe in God.” These results closely mirror the same number reported from earlier polls in 2005 and 2007. Another 9% said they, “did not believe in God, and 9% said that they were not sure.” The poll further concluded, “Significant majorities also believe in miracles (76%), heaven (75%), that Jesus Christ is God or the Son of God (73%), in angels (72%), the survival of the soul after death (71%), and in the resurrection of Christ (70%).” Likewise, Pew Forum’s 2007 U.S. Religious Landscape Survey of over 35,000 adults showed that 78% of adults in this country report belonging to various forms of the Christian faith. While religious beliefs must be respected in any client seeking mental health treatment, it would appear reasonable to include religious sensitivity and awareness training to cover this domain given the reality that the significant majority of faith-oriented clients come from a Judeo-Christian heritage.
Both chaplains and mental health providers typically receive formal education and training in multicultural issues. This includes ethnic, racial, gender, and age differences among others. Only more recently has there been an increased focus on religious and spiritual diversity from a cultural perspective. A Christian-based intervention model would likewise require a central understanding of its particular distinctives. Even though there is an accepted diversity within the subculture, Hodge (2004) makes the following observations about the nature of evangelical Christianity:
One common way of thinking about this particular population is as an inclusive, transdenominational Protestant movement characterized by (a) a relationship with God, (b) a spiritually transformed life, and (c) an authoritative view of the Bible. As discussed in the ecumenical document, Evangelicals and Catholics Together, these Christians believe that all humans have dignity, strengths, and worth as God’s image bearers, but are separated from God through sin, both individual and corporate. Turning from one’s own egocentricity to the God-man, Jesus, through a personal, existential act of faith in His finished, sacrificial death, provides the vehicle for the restoration of communion between the individual and God.
A spiritual awakening or conversion results in a transformed life. Moral conduct and personal devotion are evidenced in such forms as acts of social justice, worship, service to the poor, relaying the availability of a life-changing relationship with God to others, and Scripture reading. The Bible, which is viewed as God’s message to humankind, functions as a guidebook for faith and practice in the believer’s ongoing walk with God. Biblical narratives are retold with the expectation that individuals will encounter God in their everyday lives. These Christians refrain from privileging a material worldview that precludes the existence of the supernatural. Enlightenment-based assumptions about the materialistic nature of reality are rejected in favor of a worldview that allows for an experiential understanding of the sacred. For evangelical Christians, the spiritual and the material are not two separate realms, but a holistic unity. (p. 252)
Appropriate referrals to chaplains, other clergy members, and faith-based mental health clinicians who are equipped to engage Christian clients within their cultural framework is a valid consideration for expanded and collaborative care (Larson & Larson, 2003). According to Hodge (2004), spiritual practices such as Scripture reading, meditation, and prayer can help foster resilience and recovery from mental illness because they can, “function as a reminder for clients of God’s concern for the marginalized and disenfranchised members of society and provide hope and optimism about the future” (p.41). Spirituality gives meaning and purpose to life and can promote client welfare and growth (Steen, Engels, & Thweatt, 2006). Historically, the Bible has been a source of comfort, guidance, and spiritual direction for many who are faced with unexpected tragedy, grief and loss, or when the unexplainable occurs. Hodge (2004) further postulates that because evangelical Christians comprise the largest spiritual minority in the United States (25%), there is an identified need for mental health practitioners to understand the cultural narrative and nuances of this segment of the population. A number of indicators confirm that there is a national upward trend of clients seeking to address spiritual issues and concerns in receiving mental health services (Morrison et al, 2009; Rose, et al, 2001).
Given the fact that the United States has essentially been a nation at war for over two decades, the extant research overwhelmingly supports the benefits of spiritual integration with treatment for combat stress, Traumatic Brain Injury (TBI), PTSD, and various affective disorders. In fact, the opposite outcome is evidenced when people struggle spiritually. Witvliet et al (2005) posited that negative religious coping, especially difficulty in forgiving oneself, resulted in increased symptoms of depression and anxiety for veterans suffering from PTSD. In an extensive study conducted with PTSD patients receiving treatment in Department of Veterans Affairs programs—both outpatient (N=554) and inpatient (N=831)—Fontana and Rosenheck (2004) concluded that the severity of PTSD symptoms was exacerbated by feelings of excessive guilt and weakened religious faith. If veterans who are unable to stay connected to their belief system and faith practices face a greater risk for physiological and psychological distress (Weaver et al, 2006), then there is a strong incentive to explore the role of spirituality and faith-based interventions when considering a comprehensive health and wellness response.
A key component in the recovery of post-traumatic stress, is directly associated with a person’s consistent faith alignment (Charney, 2006; Chen & Koenig, 2006). Since the constructs of forgiveness (including self-forgiveness) and the alleviation of guilt are core themes among Christian denominations, clergy and professional caregivers are in a primary position to offer credible help when clients are having difficulty in these areas and to the extent that optimal mental health functioning is compromised. With the research literature clearly supporting the fact that trauma sufferers readily pursue spiritual care (Fontana & Rosenheck, 2005), there are a number of meaningful opportunities for mental health professionals and clergy members to collaborate more effectively in this area (Sigmund, 2003; Weaver, Koenix, & Ochberg, 2006).
Outside of pastoral counselors and chaplains trained in Clinical Pastoral Education (CPE), few clinicians have received formal training to work effectively with spiritually attuned and motivated clients (Burke et al, 1999; Schulte, Skinner, & Claiborn, 2002). This accentuates the existing need to provide competent and culturally relevant resources to counselors, especially when surveys and polling data consistently demonstrate the importance of faith to a majority of Americans. Furthermore, it is critical to respect a client’s spiritual autonomy by working within the parameters of their theological worldview (Johnson, Ridley, & Nielsen, 2000). Conversely, spiritual distress can lead to poorer health outcomes (Pargament et al, 2002). In a review on the use of spiritual interventions among Christian counselors, Walker, Gorsuch, and Tan (2005) found not only that the most commonly identified factor was the therapist’s personal religious beliefs, attitudes, and behavior, but that when congruence existed between client and therapist, the treatment process was enhanced. While many mental health practitioners acknowledge the importance of spiritual values to their clients, the majority of clinicians inadequately assess this domain (Hathaway, Scott, & Garver, 2004). Linking clients with church and para-church resources has proven to be an effective approach (Shifrin, 1998).
Indeed, “With regard to informed consent, counselors’ disclosure about spirituality matters in counseling could enhance a client’s informed choice and appropriate counselor referrals” (Steen et al, 2006, p.112).
Spirituality as a Cultural Competency for Educators and Clinicians
The Council for the Accreditation of Counseling and Related Educational Programs (CACREP) has recognized the deficiency that exists in most graduate academic institutions regarding spiritual competency. Modalities that are utilized may incorporate spiritual autobiographies, role playing, journaling, class presentations, spiritual readings, etc. (Dobmeier & Reiner, 2012). Yet, there remains a lack of effective training protocols and an ongoing general discomfort among counselor trainees and faculty members in addressing and even integrating spirituality within their curriculum and programs (Hagedorn & Gutierrez, 2009). Even though CACREP has mandated in their 2009 Standards the need to address spirituality in the core curriculum of counselor education programs, at present, neither CACREP nor any other accrediting body specifically addresses spiritually-oriented counseling certificate programs.
Research supports the notion that when a client receives care within the confines of his/her basic worldview and foundational value system—of which religious affiliation is a significant marker for most—outcomes are more positive (Fallot, 2001; Hage et al, 2003; Hodge, 2006; Koenig et al., 2001; Larson, 2003). Koenig et al’s (2001) systematic review of nearly 1,600 published health-related studies concludes that the integration of a spiritual paradigm not only demonstrated increased levels of self-esteem, social support and life satisfaction, but simultaneously reduced levels of anxiety, depression, loneliness, and suicide. The implication is that treatment providers need to think and practice in terms of a bio-psycho-social-spiritual orientation. Based in part on the principles related to attachment theory (Bowlby, 1969), it has also been shown that people who report a deeper sense of spirituality demonstrate better stress management, higher self-esteem, and greater interpersonal competence (Hill & Pargament, 2003).
Hence, there is a growing need for counselor education programs to more actively incorporate training in spirituality and spiritual interventions from an ethical and spiritual competence perspective (Briggs & Rayle, 2005; Walker, Gorsuch, & Tan, 2004; Hall, Dixon, & Mauzey, 2004; Grams, Carlson & McGeorge, 2007). In recent years, there has been a push for counseling practitioners—across disciplines and at all levels—to develop spiritual competencies in the assessment and treatment of mental and emotional disorders (Hodge, 2004). This includes social workers (Gilligan & Furness, 2006), professional counselors (Young et al, 2007), psychologists (Hage et al, 2006), and physicians (Kliewer, 2004). In fact, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the accrediting body for most hospitals in the United States, now recommends that spiritual assessment be completed with all patients (2010). Hage et all (2006) maintain that this is a frequently neglected focus of multicultural training in most academic settings. Kliewer’s (2004) research showed that most patients view their faith as a core aspect of life and want to address issues of spirituality in the context of their medical care. However, one study of evangelical Christian clients in need of psychiatric help found that 83% of respondents believed therapists did not understand their beliefs and values, resulting in a significant hesitation to initiate services(Furman, Perry, & Goldale, 1996). Perhaps this is why a random sample of over 500 members of the American Counseling Association strongly advocated the value of faith-based competency among practitioners (Young et al, 2007).
When Values are in Conflict
Counseling by its very nature is value laden and includes both the therapist’s and the client’s worldview and value system. To conclude otherwise is to turn a blind eye and a deaf ear to this reality. One critical question that must be addressed is what to do when there appears to be a conflict of values within the therapeutic process. Although counselor self-awareness is certainly important, some researchers argue for a more constructivist approach, which by its very nature challenges the traditional view of scientific discovery and posits a value-free path to meaning making and one’s perception of objective truth (Shaw, Bayne & Lorelle, 2012). This mindset would be in direct contradiction to a Judeo-Christian orientation.
Perhaps at the forefront of this debate lies the issue of gender identity counseling. While most clinicians and researchers have adopted the conclusion that homosexuality is not considered as a mental health disorder, how should a treatment provider respond if a client seeks therapy because his/her homosexual behavior is incongruent with deeply held spiritual or religious values and those values appear to take precedent above all others? Which set of values is more valid? Should the client have the autonomy to make that decision? One of the most time-honored, cornerstone ethical principles that pertains to the mental health field, is a client’s right to self-determination—the freedom to participate in the choice and direction of treatment and in a manner that is culturally relevant. This principle is reinforced by the ethics codes of such prominent organizations as the American Psychological Association (APA) and the American Counseling Association (ACA).
Hagedorn and Gutierrez (2009) examined spiritual competencies developed by one of ACA’s divisions, the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC). In reviewing the proceedings at the 2007 ACA national conference in Detroit, Michigan, ASERVIC hosted a panel discussion of educators and clinicians. These individuals were intentionally identified as being nationally recognized for their expertise in teaching and research in the area of spirituality in counseling. Though the efforts of these panel members are to be commended, Dobmeier and Reiner (2012) found that most counseling students and interns are by in large, still unaware of ASERVIC at all. In fact, there are only a few clearly articulated content and classroom management strategies for preparing future counselors (Shaw, Bayne & Lorelle, 2012). The following are eight of the competencies that have particular relevance to the discussion:
Competency #2 – The professional counselor recognizes that the client’s beliefs (or absence of beliefs) about spirituality and/or religion are central to his or her worldview and can influence psychosocial functioning.
Competency #5 – The professional counselor can identify the limits of his or her understanding of the client’s spiritual and/or religious perspective and is acquainted with religious and spiritual resources, including leaders, who can be avenues for consultation and to whom the counselor can refer.
Competency #6 – The professional counselor can identify limits of her/his understanding of a client’s religious or spiritual expression, and demonstrate appropriate referral skills and generate possible referral sources.
Competency #7 – The professional counselor responds to client communications about spirituality and/or religion with acceptance and sensitivity.
Competency #8 – The professional counselor uses spiritual and/or religious concepts that are consistent with the client’s spiritual and/or religious perspectives and that are acceptable to the client.
Competency #9 – The professional counselor can recognize spiritual and/or religious themes in client communication and is able to address these with the client when they are therapeutically relevant.
Competency #12 – The professional counselor sets goals with the client that are consistent with the client’s spiritual and/or religious perspectives.
Competency #13 – The professional counselor is able to a) modify therapeutic techniques to include a client’s spiritual and/or religious perspectives, and b) utilize spiritual and/or religious practices as techniques when appropriate and acceptable to a client’s viewpoint.
As evidenced in the language of these statements—in particular # 8 and #12—a client’s spiritual and religious values are indeed valid and reasonable determinants for the focus and direction of treatment. The critical alliance counselors must build with their clients is based on an abiding presence of trust. Counselors are expected to utilize appropriate empathy skills, and in doing so, be able to understand the client’s perspective, accept differences between themselves and their client’s beliefs and values, and also facilitate the personal development of the client’s spirituality and growth, regardless of the counselor’s personal views (Corey et al, 2011). However, whether it is by design or a general lack of awareness, when counselors avoid, “client material [related to spirituality], clients may perceive…[counselors] to be less expert, attractive, and trustworthy” (Rosenberger & Hayes, 2002, p. 222). Clinicians have an ethical responsibility to treat their clients within their relevant culture and value system, or to make an appropriate referral whenever there is a lack of competence (based on education, training, and experience), expertise, or the inability to facilitate a productive therapeutic process.
Again, in outlining the standard of respecting a client’s values and beliefs, including those that are spiritual or religious in nature, the 2014 ACA Code of Ethics provides some general guidance:
A.1.a. Primary Responsibility – The primary responsibility of counselors is to respect the dignity and promote the welfare of clients.
A.4.b. Personal Values – Counselors are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. Counselors respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the values are inconsistent with the client’s goals or are discriminatory in nature.
A.11.b. Inability to Assist Clients – Counselors refrain from referring prospective and current clients based solely on the counselor’s personally held values, attitudes, beliefs, and behaviors. Counselors respect diversity of clients and seek training in areas in which they are at risk of imposing their values onto clients, especially when the values are inconsistent with the client’s goals or are discriminatory in nature.
C.2.a. Boundaries of Competence – Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Whereas multicultural counseling competency is required across all counseling specialties, counselors gain knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor in working with a diverse client population.
C.5. Nondiscrimination – Counselors do not condone or engage in discrimination against prospective or current clients, students, employees, supervisees, or research participants based on age, culture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital/partnership status, language preference, socioeconomic status, immigration status, or any basis proscribed by law.
Glossary of Terms: Multicultural/Diversity Counseling – counseling that recognizes diversity and embraces approaches that support the worth, dignity, potential, and uniqueness of individuals within their historical, cultural, economic, political, and psychosocial contexts.
Similarly, the 2003 APA Code of Ethics (amended in 2010) guides the practice of psychologists.
Principle E: Respect for People’s Rights and Dignity – Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making. Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.
2.01 Boundaries of Competence (a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.
(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.
Excerpts from the 2015 American Association of Marriage & Family Therapy (AAMFT) Code of Ethics:
1.1 Non-Discrimination – Marriage and family therapists provide professional assistance to persons without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin, sexual orientation, gender identity or relationship status.
1.10 – Marriage and family therapists respectfully assist persons in obtaining other therapeutic services if the therapist is unable or unwilling to provide professional help.
1.11 – Marriage and family therapists do not abandon or neglect clients in treatment without making reasonable arrangements for the continuation of treatment.
And finally, the following are also pertinent excerpts from the definitive Code of Ethics for Christian counseling and caregiving by the American Association of Christian Counselors (2014).
1-010: Affirming Human Worth and Dignity
Christian counselors recognize and uphold the inherent, God-given worth and dignity of every human person, from the preborn to those on death’s bed. Human beings are God’s creation and consequently, are due all the rights, respect and ordered logic that this fact of creation entails. Therefore, Christian counselors express appropriate care towards any client, service-inquiring person, or anyone encountered in the course of practice or ministry, without regard to race, ethnicity, gender, sexual behavior or orientation, socioeconomic status, age, disability, marital status, education, occupation, denomination, belief system, values, or political affiliation. God’s love is unconditional and, at this level of concern, so must that be of the Christian counselor.
ES1-300: Consent in Christian Counseling – A Call to Integrity
The fundamental right of client self-determination is a foundational pillar for counselors and their clients. Consent allows for the counselor to operate transparently and with integrity, and for the client to make an informed and voluntary decision to engage in the helping process.
1-330: Consent for Biblical and Spiritual Practices in Counseling
Christian counselors do not presume that all clients want or will be receptive to explicit, spiritual Judeo-Christian interventions in counseling and therefore, obtain consent that honors client choice, receptivity to these practices, and the timing and manner in which these elements are introduced. This includes, but is not limited to the following: (1) prayer for and with clients; (2) Bible reading and reference; (3) spiritual meditation; (4) the use of biblical and religious imagery or music; (5) assistance with spiritual formation and discipline; (6) incorporation of fasting in the treatment plan as a spiritual discipline; and (7) other common spiritual practices.
ES1-500: Cultural Regard in Christian Counseling – A Call to Dignity
Cultural, ethnic and racial diversity are important factors for consideration in the delivery of counseling related services. Cultural competency signifies a minimal level of knowledge and awareness that represents such things as the values, norms, and traditions of another that influence perception, thoughts, attitudes, beliefs, identity, communication, relational dynamics, behaviors, life experiences, customs, spirituality and the understanding of the cause, symptomology and remedy of human problems.
1-530: Working with Persons of Different Faiths, Religions, and Values
Counselors work to understand the client’s belief system, always maintain respect for the client and strive to understand when faith and values issues are important to the client and foster values-informed client decision-making in counseling. Counselors share their own faith orientation only as a function of legitimate self-disclosure and when appropriate to client need, always maintaining a posture of humility. Christian counselors do not withhold services to anyone of a different race, ethnic group, faith, religion, denomination, or value system.
1-530-a: Not Imposing Values
While Christian counselors may expose clients and/or the community at large to their faith orientation, they do not impose their religious beliefs or practices on clients.
Various ethics codes, like the ones cited above, clearly articulate and protect a client’s beliefs and value system, including those related to spirituality and religious practice. Clinicians, researchers, educators and accrediting bodies must help ensure that those individuals seeking mental health treatment are able to do so in a manner that consistently advocates for their right to self-determination and the freedom to engage treatment environments that respect their cultural diversity. Appropriate and professional referrals are a well accepted practice in cases where a conflict of values exists.
Yes spirituality is mysterious and yes, it is real. Faith and faith-based treatment models continue to show promise in the literature and researchers should be encouraged to pursue the ongoing exploration of this dynamic construct. Spirituality, while intensely personal, offers the “believer” an anchor for the soul. It has a hopeful contagion effect that can motivate a client and enhance the change process in ways that are transformational because it incorporates the whole person. Does faith make a difference? It can.
American Association of Christian Counselors (2014). AACC code of ethics. www.aacc.net/about-us/code-of-ethics/
American Association of Marriage and family Therapy (2015). AAMFT code of ethics. www.aamft.org/iMIS15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx
American Counseling Association (2014). ACA code of ethics. www.counseling.org/Resources/aca-code-of-ethics.pdf
American Foundation for Suicide Prevention (2010). About suicide: Facts and figures. Retrieved April 7, 2010 from www.afsp.org/index.cfm?fuseaction=home.viewPage&page_id=1.
American Psychological Association (2010). APA code of ethics. www.apa.org/ethics/code/index.aspx
Baetz, M.; Larson, D. B.; Marcoux, G.; Bowen, R.; & Griffin, R. (2002). Canadian psychiatric inpatient religious commitment: An association with mental health. Canadian Journal of Psychiatry, 47, 159-165.
Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York: Basic Books.
Briggs, M. K. & Rayle, D. (2005). Incorporating spirituality into care counseling courses: Ideas for classroom application. Counseling and Values, 50(3), 63-75.
Bruce, W. M. (2000). Public administrator attitudes about spirituality: An exploratory study. American Review of Public Administration, 30(4), 460-372.
Burke, M. T.; Hackney, H.; Hudson, P.; Miranti, J.; Watts, G. A.; & Epp, L. (1999). Spirituality, religion, and CACREP curriculum standards. Journal of Counseling & Development, 77, 252-257.
Charney, D. S. (2006). In session with Dennis S. Charney, MD: Resilience to stress. Primary Psychiatry, 13(8), 39-41.
Chen, Y. Y. & Koenig, H. G. (2006). Traumatic stress and religion: Is there a relationship? A review of empirical findings. Journal of Religion and Health, 45(3), 371-381.
Comstock, G. W. & Partridge, K. B. (1972). Church attendance and health. Journal of Chronic Disease, 25, 665-672.
Corey, G., Corey, M., & Callanan, P. (2011). Issues & ethics in the helping professions (8th ed.). Pacific Grove, CA: Brooks/Cole.
Dobmeier, R. A. & Reiner, S. M. (2012). Spirituality in counselor education curriculum: A national survey of student perceptions. Counseling & Values, 57, 47-65.
Fairholm, G. W. (1997). Capturing the heart of leadership: Spirituality and community in the new American workplace. Westport: Praeger.
Fallot, R. D. & Heckman, J. P. (2005). Religious/spiritual coping among women trauma survivors with mental health and substance abuse disorders. Journal of Behavioral Health Services & Research, 32(2), 215-226.
Falsetti, S.; Resick, P.; & Davis, J. (2003). Changes in religious beliefs following trauma. Journal of Traumatic Stress, 16(1), 391-398.
Fitchett, G.; Burton, L. A.; & Sivan, A. B. (1997). The religious needs and resources of psychiatric inpatients. The Journal of Nervous and Mental Disease, 185(5), 320-326.
Fallot, R. D. (2001). Spirituality and religion in psychiatric rehabilitation and recovery from mental illness. International Review of Psychiatry, 13(1), 110-116.
Fontana, A. & Rosenheck, R. (2004). Trauma, change in strength of religious faith, and mental health service among veterans treated for PTSD. Journal of Nervous and Mental Disease, 192(9), 579-584.
Fontana, A. & Rosenheck, R. (2005). The role of meaning in the pursuit of treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 18(2), 133-136.
Furman, L. D.; Perry, D.; & Goldale, T. (1996). Interaction of evangelical Christians and social workers in the rural environment. Human Services in The Rural Environment, 19, 5-8.
Gall, T., Charbonneau, C., Clarke, N. H., Grant, K., Joseoh, A., & Shouldice, L. (2005). Understanding the nature and role of spirituality in relation to coping and health: A conceptual framework. Canadian Psychology, 46(2), 88-104.
Gilligan, P. & Furness, S. (2006). The role of religion and spirituality in social work practice: Views and experiences of social work students. British Journal of Social Work, 36, 617-637.
Glover-Graf, N. M.; Marini, I.; Baker, J.; & Buck, T. (2007). Religious and spiritual beliefs and practices of persons with chronic pain. Rehabilitation Counseling Bulletin, 51(1), 21-33.
Grams, W. A.; Carlson, T. S. & McGeorge, C. R. (2007). Integrating spirituality into family therapy training: An exploration of faculty member’s beliefs. Contemporary Family Therapy, 29, 147-161.
Gregory, C. (2008). The effect of psychologist’s disclosure of personal religious background on prospective clients. Mental Health, Religion & Culture, 11, 369-373.
Hage, S. M.; Hopson, A.; Siegel, M.; Payton, G. & Defanti, E. (2006). Multicultural training in spirituality: An interdisciplinary review. Counseling and Values, 50(3), 217-234.
Hagedorn, W. B. & Gutierrez, D. (2009). Integration versus segregation: Applications of the spiritual competencies in counselor education programs. Counseling and Values, 54(3), 32-47.
Hall, C. R.; Dixon, W. A. & Mauzey, E. D. (2004). Spirituality and religion: Implications for counselors. Journal of Counseling & Development, 82(3), 504-507.
Hathaway, W. L., Scott, S. Y, & Garver, S. A. (2004). Assessing religious/spiritual functioning: A neglected domain in clinical practice? Professional Psychology: Research and Practice, 35, 97.
Heinz, A; Epstein, D. H; & Preston, K. L. (2007). Spiritual/religious experiences and in-treatment outcome in an inner-city program for heroin and cocaine dependence. Journal of Psychoactive Drugs, 39(1), 41-49.
Harris Interactive. What people do and do not believe in. 2009-12-15. Retrieved 2011-07-17.
Hodge, D. R. (2004). Developing cultural competency with evangelical Christians. Families in Society, 85(2), 251-262.
Hodge, D. R. (2004). Spirituality and people with mental illness: Developing spiritual competency in assessment and intervention. Families in Society, 85(1), 36-45.
Hodge, D. R. (2006). Spiritually modified cognitive therapy: A review of the literature. Social Work, 51(2), 157-166.
Johnson, W. B.; Devries, R.; Ridley, C. R.; Pettorini, D; & Peterson, D. R. (1994). The comparative efficacy of Christian and secular rational-emotive therapy with Christian clients. Journal of Psychology and Theology, 22, 130-140.
Johnson, W. B.; Ridley, C. R.; & Nielsen, S. L. (2000). Religiously sensitive rational emotive behavior therapy: Elegant solutions and ethical risks. Professional Psychology: Research and Practice, 31, 14-20.
Joint Commission on Accreditation of Healthcare Organizations (2010). Spiritual assessment. In Standards-Frequently asked questions. Retrieved April 5, 2010 from www.jacho.org/standard/pharmfaq_mpfrm.html.
Kendler, K. S.; Gardner, C. O.; & Prescott, C. A. (1997). Religion, psychopathology, and substance use and abuse: A multimeasure, genetic-epidemiologic study. American Journal of Psychiatry, 154, 322-329.
Kliewer, S. (2004). Allowing spirituality into the healing process. The Journal of Family Practice, 53(8), 22-31.
Koenig, H. G. (2000). Religion, spirituality and medicine: Application to spiritual practice. Journal of the American Medical Association, 284, 1708.
Koenig, H. G.; McCullough, M. & Larson, D. (2001). Handbook of religion and health. New York: Oxford University Press.
Larson, D. B. & Larson, S. S. (2003). Spirituality’s potential relevance to physical and emotional health: A brief review of quantitative research. Journal of Psychology and Theology, 31(1), 37-51.
Lerner, M. (2000). Spirit matters: Global healing and the wisdom of the soul. Charlottesville, VA: Hampton Roads Publishing Company, Inc.
Lietz, C. A. & Hodge, D. R. (2013). Incorporating spirituality into substance abuse counseling: Examining the perspectives of service recipients and providers. Journal of Social Research, 39(4), 498-510.
McCullough, M. E.; Hoyt, W. T.; Larson, D. B.; Koenig, H. G.; & Thoresen, C. E. (2000). Religious involvement and mortality: A meta-analytic review. Health Psychology, 19(3), 211-222.
McCullough, M. E. & Larson, D. B. (1999). Religion and depression: A review of the literature. Twin Research, 2, 126-136.
McMinn, M.; Hathaway, W.; Woods, S. & Snow, K. (2009), What American Psychological Association leaders have to say about psychology of religion and spirituality. Psychology of Religion and Spirituality, 1, 3-13.
Miller, W. R. & Thoresen, C. E. (2003). Spirituality, religion, and health: An emerging research field. American Psychologist, 58, 24-35.
Mitroff, I. I., & Denton, E. A. (1999). A spiritual guide of corporate America: A hard look at spirituality, religion, and values in the workplace. San Francisco: Jossey-Bass.
Morrison, J. Q.; Clutter, S. M.; Pritchett, E. M.; & Demmitt, A. (2009). Perceptions of clients and counseling professionals regarding spirituality in counseling. Counseling and Values, 53(4), 183-194
Mueller, P. S.; Plevak, D. J.; & Rummans, T. A. (2001). Religious involvement, spirituality and medicine: Implications for clinical practice. Mayo Clinic Proceedings, 76(12), 1225-1235.
Narayanasamy, A. (2004). Spiritual coping mechanisms in chronic illness: A qualitative study. Journal of Clinical Nursing, 12, 116—117.
National Institute of Mental Health (2010). Statistics. Retrieved April 7, 2010 from www.nimh.nih.gov/index.shtml.
Nichols, L. M. & Hunt, B. (2011). The significance of spirituality for individuals with chronic illness: Implications for mental health counseling. Journal of Mental Health Counseling, 33(1), 51-66.
Nisbet, P. A.; Duberstein, P. R.; Yeates, C.; & Seidlitz, L. (2000). The effects of participation in religious activities on suicide versus natural deaths in adults 50 and older. Journal of Nervous and Mental Disease, 188, 543-546.
O’Reilly, M. L. (2004). Spirituality in mental health clients. Journal of Psychosocial Nursing & Mental Health Services, 42(7), 44-33.
Pargament, K. I.; Koenig, H. G.; Tarakeshwar, N.; and Hahn, J. (2001). Religious struggle as a predictor of mortality among medically ill elderly patients: A two-year longitudinal study. Archives of Internal Medicine, 57(1), 1881-1885.
Parker, M. W. (2001a). Soldier and family wellness across the life course: A developmental model of successful aging, spirituality, and health promotion, Part I. Military Medicine, 166(6), 485-490.
Parker, M. W. (2001b). Soldier and family wellness across the life course: A developmental model of successful aging, spirituality, and health promotion, Part II. Military Medicine, 166(6), 485-490.
Pew Forum (2007). U.S. religious landscape survey. http://religions.pewforum.org/reports#. Retrieved 07-17-2011.
Post, B. C. & Wade, N. G. (2014). Client perspectives about religion and spirituality in group counseling. The Counseling Psychologist, 42(5), 601-627.
Rasic, D.; Belik, S; Elias, B.; Katz, L.; & Sareen, J. (2001). Spirituality, religion and suicidal behavior in a nationally representative sample. Journal of Affective Disorders, 114(1), 32-40.
Ripley, J. S.; Worthington, E. L.; Davis, E. B.; Leon, C.; Berry, J. W.; Smith, A.; & Sierra, T. (2014). Efficacy of religion-accommodative strategic hope-focused theory applied to couples therapy. Couple and Family Psychology: Research and Practice, 3(2), 83-98.
Rose, E. M., Westefeld, J. S., & Ansley, T. N. (2001). Spiritual issues in counseling: Clients’ beliefs and preferences. Journal of Counseling Psychology, 48, 61-71.
Rosenberger, E. W., & Hayes, J. A. (2002). Origins, consequences, and management of countertransference: A case study. Journal of Counseling Psychology, 49, 221-232.
Saenz, R. & Waldo, M. (2013). Client’s preferences regarding prayer during counseling. American Psychological Association, 5(40), 325-334.
Schulte, D. L.; Skinner, T. A.; & Claiborn, C. D. (2002). Religious and spiritual issues in counseling psychology training. The Counseling Psychologist, 30, 118-134.
Shaw, B. M.; Bayne, H.; & Lorelle, S. (2012). A constructivist perspective for integrating spirituality into counselor training. Counselor Education & Supervision, 51, 270-280.
Shaw, A.; Joseph, S.; & Linley, P. A. (2005). Religion, spirituality, and posttraumatic growth: A systematic review. Mental Health, Religion & Culture, 8(1), 1-11.
Shifrin, J. (1998). The faith community as a support for people with mental illness. In R. D. Fallot (Ed.), Spirituality and religion in recovery from mental illness (pp.69-81). San Francisco: Jossey-Bass.
Sigmund, J. A. (2003) Spirituality and trauma: The role of clergy in the treatment of posttraumatic stress disorder. Journal of Religion and health, 42(3), 221-229.
Sphon, W. (1997). Spirituality and ethics: Exploring the connections. Theological Studies, 58, 109-123.
Steen, R. L., Engels, D., & Thweatt, W. T., III. (2006). Ethical aspects of spirituality in counseling. Counseling and Values, 50,108-11
Tan, S. Y. (2003). Integrating spiritual direction into psychotherapy: Ethical issues and guidelines. Journal of Psychology and Theology, 31, 14-23.
Teasdale, T. W. & Engberg, A. W. (2001). Suicide after traumatic brain injury: A population study. Journal of Neurology, Neurosurgery and Psychiatry, 71, 436-440.
Tepper, L; Rogers, S. A.; Coleman, E. M.; Maloney, H. N. (2001). The prevalence of religious coping among persons with persistent mental illness. Psychiatric Services, 52(5), 660-665.
Tischler, L., Biberman, J., & McKeage, R. (2002). Linking emotional intelligence, spirituality and workplace performance. Journal of Managerial Psychology, 17(3), 203-218.
Walker, D. F.; Gorsuch, R. L.: & Tan, S. Y. (2005). Therapists’ use of religious and spiritual interventions in Christian counseling: A preliminary report. Counseling and Values, 49(2), 107-119.
Weaver, A. J.; Koenig, H. G.; & Ochberg, F. M. (2006). Posttraumatic stress, mental health professional, and the clergy: A need for collaboration, training, and research. Journal of Traumatic Stress, 9(4), 847-856.
Weaver, A. J.; Pargament, K. J.; Flannelly, K. J.; & Oppenheimer, J. E. (2006). Trends in the scientific study of religion, spirituality and health. Journal of Religion and Health, 24(2), 208-214.
Witvliet, C. V.; Phipps, K. A.; Feldman, M. E.; & Beckham, J. C. (2005). Posttraumatic mental and physical health correlates of forgiveness and religious coping in military veterans. Journal of Traumatic Stress, 17(3), 269-273.
Young, J. S.; Wiggins-Frame, M. & Cashwell, C. S. (2007). Spirituality and counselor competence: A national survey of American Counseling Association members. Journal of Counseling and Development, 85(1), 47-53.