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Running head: INTEGRATING SPIRITUALITY AND RELIGION i
INTEGRATING SPIRITUALITY AND RELIGION INTO COUNSELING
Colleen Kilmer
A Capstone Project submitted in partial fulfillment of the
requirements for the Master of Science Degree in
Counselor Education at
Winona State University
Spring 2012
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INTEGRATING SPIRITUALITY AND RELIGION ii
Winona State University
College of Education
Counselor Education Department
CERTIFICATE OF APPROVAL
__________________________
CAPSTONE PROJECT
___________________
Integrating Spirituality and Religion into Counseling
This is to certify that the Capstone Project of
Colleen Kilmer
Has been approved by the faculty advisor and the CE 695 – Capstone Project
Course Instructor in partial fulfillment of the requirements for the
Master of Science Degree in
Counselor Education
Capstone Project Supervisor: Name
Approval Date: __5/2/12____________________
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INTEGRATING SPIRITUALITY AND RELIGION iii
Abstract
Many counselor education programs fail to sufficiently address the use of spirituality and
religion in the counseling setting, resulting in a large portion of counselors who are ill equipped
to address spirituality with clients. The following literature review explores why it is essential for
the health and the well being of clients to explore their religious and/or spiritual beliefs, or lack
of beliefs, followed by a discussion of how counselors can become competent in addressing
spiritual and/or religious matters. Utilizing clients’ spirituality and/or religion can be very
beneficial, and it can be used in many different situations.
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Contents
Introduction ………………………………………………………………………………….…..1
Review of Literature ……………………………………………………………………………..3
The Difference between Religion and Spirituality……………………………………...3
The Importance of Addressing Spirituality and Religion……………….………………4
ASERVIC Competencies and How to Become Competent………………………….….7
Culture and Worldview………………………………………………………….7
Counselor Self-Awareness………………………………………………………9
Human and Spiritual Development……………………………………………..12
Communication………………………………………………………………….13
Assessment………………………………………………………………………15
Diagnosis and Treatment………………………………………………………..17
Spirituality, Religion and Depression…………………….….…………………………20
Spirituality, Religion and Addictions Counseling………..…………………………….22
Spirituality, Religion and Dying……………………………………………….…….…23
Limitations of Addressing Spirituality and Religion in Counseling...........................…...25
Conclusion ………………..…………………………………………………………….……….27
References ……………………………………………………………………………………..29
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Introduction
In the field of counseling, religious and spiritual issues are often avoided (Nelson,
Manning Kirk, Ane, & Serres, 2011). Many psychology and counselor education programs give
only cursory training in the area, if the topic is even addressed (Rose, Westefeld, & Ansley,
2008). This is due to the fact that counseling is based in psychology, a scientific field, which has
traditionally neglected issues of a spiritual nature (Nelson et al., 2011). It is also due to the
traditional practice in the United States of separating religion and education (Cashwell & Young,
2011). According to Walker, Gorsuch, and Tan, “more than two thirds of Americans consider
personal spiritual practices to be an important part of their daily lives” (2004, p. 70). And more
than 90% of Americans polled believed in God, or in some higher power (Chawell & Young,
2011). Because so many Americans consider spirituality important, it follows that counselors
will likely come into contact with clients who want to address issues regarding spirituality and
religion. One study attempted to gauge whether or not participants would like to discuss spiritual
or religious matters in the counseling setting (Rose et al., 2008). The study found that over half
of the clients who responded preferred to discuss spiritual and religious concerns (Rose et al.,
2008). Because of the lack of training, most of the integration of spirituality and religion that
occurs in counseling happens through intrapersonal integration of therapists’ own spiritual or
religious experiences, resulting in risks to the client, such as the counselor imposing his or her
own beliefs on the client, or inappropriately applying religious or spiritual interventions (Walker
et al., 2004).
To fully grasp the importance of appropriately addressing spiritual and religious issues in
counseling, and the importance of becoming competent integrating spiritual and religious issues
into counseling, one must first understand the differences between religion and spirituality, and
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how clients identify themselves with regard to spirituality and religion. Next, one must
understand how essential religion and spirituality can be to clients’ well being. It is also
important for one who is seeking knowledge about how and when to address issues of a spiritual
nature in counseling to become thoroughly familiar with the ASERVIC (The Association for
Spiritual, Ethical, and Religious Values in Counseling) competencies for counselors. While
learning each competency, is also essential that one learns how to become competent in
integrating spiritual and religious issues in counseling, and why spirituality and religion are so
important. One should also become aware of the different situations and scenarios when it
would be appropriate and beneficial to address religion and/or spirituality. Finally, one must
understand when it is inappropriate to discuss such matters, and the limitations of addressing
spirituality and religion in counseling.
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Review of Literature
The Difference Between Religion and Spirituality
As one commences the process of becoming competent in integrating spirituality and
religion into counseling, it is first important for one to understand the difference between religion
and spirituality. There are many different definitions that distinguish between religion and
spirituality. However, religion is often associated with formal, institutionalized structure
(Magaldi-Dopman & Parker-Taylor, 2010). Spirituality is much more difficult to define, but is
often characterized by a general feeling of closeness and connectedness with the sacred
(Worthington, Hook, Davis, & McDaniel, 2010). Spirituality is internal, spontaneous, universal,
and private (Cashwell & Young, 2011). For the purpose of this paper, the definition of
spirituality is “the universal human capacity to experience self-transcendence and awareness of
sacred immanence, with resulting increases in greater self-other compassion and love” (Cashwell
& Young, 2011). Religion “provides a structure for human spirituality” (Cashwell & Young,
2011, p. 9), where “engagement in the search for the sacred is shared by the group, and
considered `legitimate’” (Hill et al., 2000 as cited in Magaldi-Dopman & Parker-Taylor, 2010, p.
383).
Although there has been a great deal of debate about how to define the two terms
“religion” and “spirituality”, the majority of people, between 74% and 88%, do not distinguish
between the two (Cashwell & Young, 2011). However, it is important to understand that there is
a continuum of religiousness and spirituality, and it is essential to understand where each client
falls with regard to this continuum. Most clients will fall into the category of being both spiritual
and religious. They will either consider the two inseparable, or they will believe religion and
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spirituality strengthen each other (Cashwell & Young, 2011). Some clients will consider
themselves to be spiritual, but not religious. These clients may have a history with organized
religion, but focus on their own, personal spiritual journey. The number of people in this
category has been growing recently in the United States. Clients in these categories are often
willing to discuss their beliefs (Cashwell & Young, 2011).
The next category is religiously tolerant and indifferent clients. These clients usually are
tolerant of others’ religion, but do not feel any commitment towards organized religion. Some
clients in this category will value their own personal, spiritual journey instead (Cashwell &
Young, 2011). Another category is religiously agnostic clients. Clients in this area often have
very strong, negative feelings towards organized religion. Usually these clients have had
negative emotional experiences with organized religion, or had families of origin who were
prejudiced of organized religion (Cashwell & Young, 2011). The final category is religious but
not spiritual. Clients who are religious but not spiritual are often very involved in their religious
organizations, and will attend religious services regularly. However, these clients usually do so
from a sense of duty, or obligation, or they are afraid of the consequences of not adhering to
religious doctrines. These clients have yet to tap into their spiritual potential (Cashwell &
Young, 2011). Regardless where clients happen to fall on the continuum, it is important to
understand each client’s perspective, as well as each client’s readiness and willingness to discuss
his or her spiritual/religious beliefs, or lack thereof.
The Importance of Addressing Spirituality and Religion
Many theories and studies reveal the importance of attending to one’s spiritual well
being. Although historically in the field of counseling, spirituality, and the idea of the soul, have
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been left largely untouched by mental health professionals, it is interesting to note the irony that
the profession of counseling hides under the scholarly, scientific title of “psychology”, a term
that literally means “the study of the soul” (Webb, 2006). Yet there are still many theories and
theorists who had spiritual ideas. Maslow’s theory of self-actualization is spiritual at its core,
and Carl Jung emphasized ideas of a spiritual nature, believing the impulse toward spirituality is
vital to the human experience (Cashwell & Young, 2011). Another exception to a history of the
omission of spiritual issues in counseling is Carl Rogers’ person-centered approach. However,
even Carl Rogers did not label his theory as being spiritual. Instead, he used more acceptable
terms such as “unconditional positive regard” (Webb, 2006).
Many different theories emphasize the importance of holistic wellness, which includes a
dimension of spirituality. The idea of spiritual wellness originated from a medical wellness
model. A health specialist, Bensley (1991), believed wellness was an integration of dimensions
of human functioning (Westgate, 1996). These dimensions include social, mental, emotional,
physical, and spiritual (Westgate, 1996). According to Westgate, an innate part of human
functioning is spirituality, which, ideally, is able to integrate into other dimensions of life so as to
maximize potential with regard to self-actualization and personal growth (1996).
Another model of wellness that is holistic in nature was developed from Adler’s five life
tasks, and is called the Wheel of Wellness model. This model has spirituality at the core of well
being (Dailey, Curry, Harper, Hartwig Moorhead, & Gill, 2011). The original Wheel of
Wellness was modified due to evidence based practice, based on factor analysis. Thus, the
Wheel of Wellness became the Indivisible Self (Dailey et al., 2011). The Indivisible Self has
five factors: Essential Self, Creative Self, Coping Self, Social Self, and Physical Self (Dailey et
al., 2011). According to the Indivisible Self model, a main component of Essential Self is
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spirituality. Spirituality includes “an existential sense of meaning for life and one’s purpose”
(Dailey et al., 2011). One tenet of the Indivisible Self model is that if there is a change in one
dimension, it affects functioning in other dimensions (Dailey et al., 2011). Because all factors in
this model are indivisible, spirituality is a fundamental element of wellness (Dailey et al. 2011).
Spirituality and/or religion can be very beneficial when utilized in counseling, and should
be considered a strength in clients who have strong spiritual or religious beliefs. Many clients
use religious coping strategies, which have been found to be beneficial (Cashwell & Young,
2011). A large amount of empirical evidence exists showing that spirituality and religion
provide an important reference for clients to learn to cope when they have intractable problems
such as terminal illness or chronic mental illness (Cashwell & Young, 2011). Appropriately
integrating spirituality into the counseling setting can be effective in instilling insight, hope, and
change, each of which is an essential element of the counseling process (Dailey et al., 2011).
Because religion has been consistently present in human society for much of its
existence, it follows that religion, or spirituality has some social and psychological functions
(Reiner, 2007). Both spirituality and religion have been identified as having important
connections to one’s mental health; those who report they feel close to God have less depression,
less psychological stress and loneliness, and greater self-esteem, as well as more psychosocial
competence (Reiner, 2007). It has been found in numerous studies that clients who are involved
in spiritual and/or religious practices tend to have better health, and fewer mental and physical
disorders (Dailey et al., 2011).
A study was completed that examined the difference of psychological and spiritual
outcomes between two groups undergoing counseling (Worthington et al. 2011). The first group
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attended religious or spiritual psychotherapies, and the other group attended alternative
psychotherapies (Worthington et al., 2011). It was found that participants from the religious or
spiritual psychotherapies outperformed participants from the alternative psychotherapies on both
psychological and spiritual outcomes (Worthington et al., 2011).
Although there is a significant lack of training in the integration of religion and
spirituality into counseling, there are still many theories that place an emphasis on the spiritual.
Many studies show the myriad positive benefits for clients that can occur when one appropriately
integrates spirituality and religion.
ASERVIC Competencies and How to Become Competent
For one to begin to become competent in integrating spirituality and religion into
counseling, a thorough knowledge of the ASERVIC (Association for Spiritual, Ethical, and
Religious Values in Counseling) spiritual competencies is necessary (Cashwell & Young, 2011).
In 1995, the first ASERVIC summit on spirituality assembled, consisting of thirteen experts, who
had the goals of defining the term “spirituality”, and identifying the key competencies needed to
ethically integrate spirituality and religion into the counseling setting (Cashwell & Young, 2011).
At this summit, experts first identified twenty-three competencies. In 2009, those competencies
were refined and reduced, and fourteen new competencies were established. These fourteen
competencies are divided into six categories: culture and worldview, counselor self-awareness,
human and spiritual development, communication, assessment, and diagnosis and treatment.
Culture and Worldview
The category of culture and worldview has two competencies. The first competency,
competency one, states: “The professional counselor can describe similarities and differences
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between spirituality and religion, including the basic beliefs of various spiritual systems, major
world religions, agnosticism, and atheism” (ASERVIC, 2009). The second competency,
competency two, states: “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” (ASERVIC, 2009).
Spiritual and religious beliefs are aspects of culture, and are wrought by one’s family of
origin and other environmental influences (Cashwell & Young, 2011). For many clients,
spiritual and religious issues are central to their worldviews. As such, spiritual and religious
beliefs often shape the way in which clients think, feel, and act (Cashwell & Young, 2011).
Counselors seeking competency with regard to their clients’ religious and spiritual worldview
can benefit from learning about various world religions and spiritual practices; by doing so,
counselors are better able to develop empathy towards the client’s worldview, especially if the
client’s beliefs are radically different from theirs (Cashwell & Young, 2011). Recognizing a
client’s spiritual and/or religious self will ideally allow the counselor to better understand clients’
various layers of identity, and how they interact to form the client’s total worldview (Cashwell &
Young, 2011).
To further become competent with culture and worldview as they pertain to spiritual
matters, counselors need to have the ability to be open to multiple perspectives, and they need
the ability to suspend their values, especially if they conflict with the client’s values (Cashwell &
Young, 2011). Often counselors wonder whether it is appropriate to self-disclose one’s beliefs.
Many counselors avoid any discussion of their beliefs with clients, for fear of imposing their
beliefs onto the client (Cashwell & Young, 2011). When clients question their counselor’s
beliefs, often it is appropriate for counselors to address clients’ concerns. Whether clients are
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concerned that the counselor’s beliefs are different from theirs, or that the counselor will not take
their beliefs seriously, the counselor can reassure clients that he or she will not try to change
clients’ beliefs, but will respect those beliefs, and is willing to explore with clients the ways their
religion and/or spirituality may be significant in the counseling process (Cashwell & Young,
2011). If the counselor feels it is appropriate, he or she can also give clients a brief self-
disclosure of his or her own beliefs, while still reassuring the client that he or she will not try to
impose his or her beliefs onto the client (Cashwell & Young, 2011).
Along with being open to different perspectives and suspending one’s values, counselors
must also be respectful of religious and spiritual authorities (Cashwell & Young, 2011). It is
especially important not to challenge these authorities in any way, as clients who place high
value on such authorities may resist participating in counseling, or terminate the session
completely, if the counselor appears to be in opposition to the religious or spiritual authority
(Cashwell & Young, 2011). The counselor can even encourage the client to bring religious texts
into session, with the purpose of discussing how the client interprets the text in relation to the
counseling issue being addressed (Cashwell & Young, 2011).
Counselor Self-Awareness
The category of counselor self-awareness contains three competencies. The first
competency, competency three, states: “The professional counselor actively explores his or her
own attitudes, beliefs, and values about spirituality and/ or religion” (ASERVIC, 2009). The
second competency, competency four, states: “The professional counselor continuously
evaluates the influence of his or her own spiritual and/or religious beliefs and values on the client
and the counseling process” (ASERVIC, 2009). The third competency, competency five, states:
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“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
(ASERVIC, 2009).
The competencies for counselor self-awareness address the importance of self-evaluation
and self-exploration in general, as well as the importance of recognizing one’s limits (Cashwell
& Young, 2011). These competencies underscore the need for counselors to explore their
personal beliefs, and to explore how those beliefs impact their relationships with clients
(Cashwell & Young, 2011). Mental health professionals who lack this self-awareness risk
providing inadequate care. Counselors deficient in self-awareness may also experience personal
as well as professional distress, such as compassion fatigue, poor judgment, burnout, and
disengagement (Cashwell & Young, 2011). It is essential that counselors seek self-knowledge
by regularly exploring their internal motivations and by assessing any possibilities of
countertransference (Cashwell & Young, 2011).
Counselors must gain self-knowledge as it pertains to spiritual and religious beliefs as
well. If counselors leave their personal spiritual beliefs and biases unexplored, there can be
many negative consequences in the counseling process. Some examples of the negative effects
due to the counselor’s lack of spiritual self-awareness include unintentionally invalidating the
client’s spiritual experiences, failing to recognize and address important client issues, and failing
to identify the client’s positive spiritual coping skills (Cashwell & Young, 2011).
Before starting work with clients who would like to address spirituality or religion in
counseling, counselors must first become comfortable with their own spiritual and religious
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values and beliefs (Cashwell & Young, 2011). It behooves counselors to answer for themselves
spiritual and existential questions that commonly arise with clients, such as “‘What does life
mean?’ and ‘Where am I going?’” (Cashwell & Young, 2011, p. 73). McLennan et al. identified
four steps to help counselors on the journey to spiritual self-awareness (as cited in Cashwell &
Young, 2011). The first step involves reflecting on how one’s attitudes, values, and beliefs have
developed over the life span. Next, one must explore personal prejudices, biases, doubts, and
fears. (Cashwell & Young, 2011). Third, one “explores the assimilation of spirituality/religion
into the counseling process itself by examining connections among mind, body, and spirit”
(Cashwell & Young, 2011, p. 75). Finally, in the fourth step, one continuously assesses one’s
comfort levels while discussing spiritual and religious matters with clients, especially when the
client’s beliefs are different from the counselor’s own (Cashwell & Young, 2011).
The fifth competency refers to counselors understanding their limits when working with
clients (Cashwell & Young, 2011). With regard to limitations concerning spiritual matters, the
first limitation one should consider is one’s ability to work with clients with spiritual or religious
concerns (Cashwell & Young, 2011). Some counselors may have spiritual concerns of their own,
and acknowledging any reluctance to address spiritual/religious matters is the first step towards
understanding one’s limitations. In such cases one must next grow in comfort and competence
when addressing spiritual matters (Cashwell & Young, 2011). A second consideration of
counselor limitations is knowing what role one has in addressing religious and spiritual concerns.
It is important for counselors to refrain from adopting the role of a religious leader (Cashwell &
Young, 2011). A third limitation for counselors to consider is whether or not to implement
explicit or implicit interventions (Cashwell & Young, 2011). Explicit interventions refer to the
counselor utilizing spiritual practices in counseling, such as reading religious texts, or including
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meditation or prayer in session (Cashwell & Young, 2011). Counselors should only use explicit
approaches if they are familiar with a particular religion, and if they are competent in integrating
spirituality and religion into counseling (Cashwell & Young, 2011). Implicit approaches require
less in-depth knowledge, and include respectful listening to themes and patterns in
communication without endorsing any one religious or spiritual perspective (Cashwell & Young,
2011).
Human and Spiritual Development
The category of human and spiritual development contains one competency. Competency
six states: “The professional counselor can describe and apply various models of spiritual and/or
religious development and their relation to human development” (ASERVIC, 2009). It is
important to note that spiritual development has been identified as a normal part of the human
development process (Cashwell & Young, 2011). To become competent, one must familiarize
oneself with the different theories of spiritual development. Some models of spiritual
development one might consider familiarizing oneself with are Fowler’s stages of faith, Oser and
Gmunder’s religious judgment, Washburn’s transpersonal development, Genia’s development of
growth, and Wilber’s integral psychology (as cited in Cashwell & Young, 2011). Understanding
the various spiritual developmental models can be of great value in the counseling process. Such
models can serve as a reference point for both the counselor and the client, and can help both
parties anticipate and even facilitate the client’s developmental direction (Cashwell & Young,
2011).
Communication
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The category of communication has three competencies. The first competency,
competency seven, states: “The professional counselor responds to client communications about
spirituality and/or religion with acceptance and sensitivity” (ASERVIC, 2009). The second
competency, competency eight, states: “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” (ASERVIC, 2009). The third competency, competency nine, states:
“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” (ASERVIC, 2009). An imperative aspect of communication is the ability to intensify
the clients’ exploration of their spirituality (Cashwell & Young, 2011). This deeper exploration
of the client’s spirituality is significant because spirituality is so extremely personal, which
means that just having a counselor express a genuine interest in clients’ beliefs, while helping
them deepen their understanding, can be therapeutic in itself (Cashwell & Young, 2011).
Historically in counselor training programs, there has been an omission of information
regarding how to address religious or spiritual matters, due to the separation of religion and state-
funded education institutions (Cashwell & Young, 2011). Therefore, there is a great deal of
confusion among counselors about how to address spiritual/religious matters (Cashwell &
Young, 2011). This lack of knowledge can hinder effective communication, which may cause
the client to feel that the counselor is not sensitive to, or even accepting of spirituality (Cashwell
& Young, 2011). Four common miscommunications regarding spirituality often occur in
counseling. The first type of miscommunication occurs when counselors do not properly
communicate the spiritual/religious content addressed in session (Cashwell & Young, 2011).
Counselors may also be inconsistent or incongruent with their communications (Cashwell &
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Young, 2011). Third, counselors may struggle with the limitations and complexities in the
language the clients use when discussing their religious and/or spiritual beliefs (Cashwell &
Young, 2011). Finally, possibly the most detrimental type of poor communication, occurs when
counselors express judgment or disapproval of clients’ statements (Cashwell & Young, 2011).
To maintain a good, trusting relationship with clients, it is essential for counselors to avoid all
four miscommunications.
Counselors must not only avoid miscommunications, but must also make an effort to
communicate in the most effective manner to allow clients the opportunity to discuss spiritual
and religious matters. One way for counselors to avoid discouraging clients from addressing
spiritual or religious concerns is to be consistent in their communication of being open to
exploring clients’ spirituality in the counseling setting (Cashwell & Young, 2011). This
openness and consistency should start at the onset of counseling, and should be present in
paperwork and informed consent (Cashwell & Young, 2011).
Another essential element of effective communication is matching the client’s
terminology (Cashwell & Young, 2011). This means the counselor should use the client’s word
Allah, not a vague, general term such as Higher Power (Cashwell & Young, 2011). Individuals
develop spiritual concepts from life experiences, and, consequently, these concepts are deeply
personal and highly individualized (Cashwell & Young, 2011). To one client, the word God
might evoke thoughts of benevolence; to another, the word God may represent wrath and
judgment (Cashwell & Young, 2011). Adopting the same spiritual language as clients allows
counselors to explore more deeply the client’s spiritual reality and personal psychology
(Cashwell & Young).
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Counselors should listen for spiritual themes as well. Oftentimes, the client will not be
comfortable enough to initiate spiritual discussion in the counseling setting, and will use indirect
messages of spirituality (Cashwell & Young, 2011). Such spiritual themes can take many forms
and can center around ideas of the sacred, a belief in a just universe, death or loss, finding
meaning and purpose, and many more (Cashwell & Young, 2011).
Finally, it is important for counselors to be aware of how various cultural dimensions
affect the counseling process (Cashwell & Young, 2011). Some cultural dimensions to consider
are gender, age, race and ethnicity, family, and sexuality (Cashwell & Young, 2011). Both overt
and covert gender-laden messages affect how individuals’ spiritual and religious identities
develop, and clients of different ages may be in different stages of spiritual development, such as
older adults using faith to cope with thoughts of their own mortality (Cashwell & Young, 2011).
Race and ethnicity are significant because they considerably shape an individual’s perspective,
as does family of origin (Cashwell & Young, 2011). One should understand a client’s sexuality
as well, as often clients’ sexual desires conflict with religious doctrine, causing internal discord
for the client (Cashwell & Young, 2011).
Assessment
The fifth category, assessment, has one competency. The tenth competency states:
“During the intake and assessment process, the professional counselor strives to understand a
client’s spiritual and/or religious perspective by gathering information from the client and/or
other sources” (ASERVIC, 2009). It is first important for counselors to know the purpose of
assessing spirituality. Some reasons might include wanting to gain a better understanding of
clients’ worldviews, to encourage clients in self exploration, to help with diagnosis, to determine
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whether or not religion and spirituality can be used as client resources, to identify spiritual and
religious problems, and to identify appropriate interventions (Cashwell & Young, 2011).
One way counselors can assess their clients’ spirituality is to utilize intake questionnaires
or counseling interviews (Richards, Bartz, & O’Grady, 2009). Some questions one might
consider asking at intake include:
1. Would the client like to discuss spiritual matters in counseling when relevant?
2. Does the client believe in God or a higher power?
3. What is God like to the client?
4. Is spirituality important to the client?
5. Does the client have a religious affiliation? If so, how important is it?
6. Does the client attend a place of gathering, such as a mosque, church, or synagogue?
7. How closely does the client, and the client’s family, follow the teachings or his or her
religion?
8. How does the client personally experience God’s guidance?
9. Does the client have any concerns related to his or her spirituality or religious
community? (Richards et al., 2009).
However, it is important for one to address the whole person during intake, and to not
focus solely on a client’s presenting problem or spirituality. A client’s physical, emotional,
spiritual, and environmental dimensions must be included as well (Cashwell & Young, 2011).
Information can also be obtained from observing the client in the initial session; by observing
client appearance one can learn much about his or her spirituality, such as with the presence of
wedding rings, head coverings, and religious symbols (Cashwell & Young, 2011). In addition to
observing appearance, counselors can include in their observation behaviors and word choice,
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which may provide clues as to a client’s spirituality, and can help facilitate discussion (Cashwell
& Young, 2011).
Another method of assessing clients’ spirituality and religious beliefs is to use a spiritual
genogram. A spiritual genogram provides a visual representation of the spiritual domain within
a family system (Dailey et al., 2011). In some cases it is beneficial for clients to understand how
the family system impacts issues of spirituality and religion (Dailey et al., 2011). Spiritual
ecomaps can be used with clients when an assessment of an individual or a family’s spiritual
domain is necessary (Dailey et al., 2011). At the center of the spiritual ecomap is a family’s
spiritual genogram. Outside of the family circle, other systems relevant to the family’s spiritual
domain are included (Dailey et al., 2011).
Diagnosis and Treatment
The sixth and final category, diagnosis and treatment, has four competencies. The first
competency, competency eleven, states: “When making a diagnosis, the professional counselor
recognizes that the client’s spiritual and/or religious perspectives can a) enhance well-being; b)
contribute to client problems; and/or c) exacerbate symptoms” (ASERVIC, 2009). The second
competency, competency twelve, states: “The professional counselor sets goals with the client
that are consistent with the client’s spiritual and/or religious perspectives” (ASERVIC, 2009).
The third competency, competency thirteen, states: “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” (ASERVIC, 2009). The fourth, and final, competency, competency fourteen,
states: “The professional counselor can therapeutically apply theory and current research
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supporting the inclusion of a client’s spiritual and/or religious perspectives and practices”
(ASERVIC, 2009).
Oftentimes, counselors who are spiritually or religiously oriented tend to under diagnose,
and counselors who favor the medical model tend to overlook spiritual influences, and diagnose
them as treatable disorders (Cashwell & Young, 2011). Counselors who are unfamiliar with the
spiritual and transformative processes may pathologize profound religious or spiritual
experiences (Cashwell & Young, 2011). Counselors who have distaste for diagnosing clients risk
labeling a diagnosable disorder as a spiritual experience (Cashwell & Young, 2011). Therefore, it
is important for counselors to maintain a balance between what is diagnosable, and what is a
spiritual experience (Cashwell & Young, 2011). The DSM-IV-TR has added a new category to
help counselors address such issues (Cashwell & Young, 2011). This category is V62.89 for
religious or spiritual problems. Such a diagnosis would apply in a situation such as a crisis of
faith, or in instances where a client experiences a high level of guilt due to involvement with a
toxic religious community (Cashwell & Young, 2011). In some cases a spiritual problem will
occur concurrently with a disorder (Cashwell & Young, 2011). For example, clients who have
obsessive-compulsive disorder can experience religious or spiritual problems in relation to the
disorder, such as ruminating about a vengeful God who does not listen to the prayers of the
unjust (Cashwell & Young, 2011). Obsessions and compulsions characterized by religious
themes are common, and have been called scrupulosity (Cashwell & Young, 2011). Finally, in
some cases, spiritual or religious problems occur due to psychopathology, as when one
experiences delusions of being God, or experiences auditory hallucinations that one claims is the
voice of God (Cashwell & Young, 2011).
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It is important that the counseling process has clear, specific goals so that sessions do not
lack direction (Cashwell & Young, 2011). There are three types of goals to keep in mind
throughout the counseling process: collaborative outcome goal setting, counselor process goals,
and spiritual and religious goals (Cashwell &Young, 2011). In collaborative outcome goal
setting both the client and the counselor develop outcome goals for the client (Cashwell &
Young, 2011). For counselor process goals, counselors develop goals for their work with clients,
with the therapeutic relationship, and with the process; these goals are typically not explicitly
shared with the client (Cashwell & Young, 2011). Spiritual and religious goals are goals
developed for the client’s spiritual/religious growth. Often, goals related to spirituality are not
very specific or behavioral, and may be more difficult to measure (Cashwell & Young, 2011).
Counselors seeking competence in treatment with regard to spirituality must understand
how to modify therapeutic techniques to include clients’ spiritual and religious viewpoints
(Cashwell & Young, 2011). One way to do this would be to include spirituality in journaling
exercises (Cashwell & Young, 2011). Counselors can also encourage mindfulness techniques,
meditation, or prayer, depending on the client’s beliefs. Counselors can also encourage spiritual
practices during sessions, by leading clients who over think problems through guided meditation
(Cashwell & Young, 2011). However, it is always important to consider clients’ beliefs, and their
comfort levels when using spiritual or religious techniques and practices in the counseling
setting.
There are many different presenting problems and situations where spiritual or religious
exploration would be beneficial. Some situations include depression, substance abuse, and
terminal illness. Although there are myriad more situations in which it is important to address
spiritual and/or religious issues, it is beyond the scope of this paper to address them all.
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Spirituality, Religion, and Depression
Between 5% and 30% of the population in the United States is affected by depression in
some way (Westagate, 1996). Often, the treatment for depression is a combination of medication
and counseling; although this treatment is effective for many clients, for a large number of
clients with depression, such treatments have only temporary effects (Behrens & Terrill, 2011).
As an awareness of the importance of holistic methods has increased, some mental health
counselors have begun to explore the spiritual realm of depression (Westgate, 1996). One such
approach is Christian-accommodative cognitive therapy for depression (Worthington et al.,
2010). In this therapy, the essential elements of cognitive therapy are present, but the therapy is
placed in a religious context (Worthington et al., 2010). The results of a meta-analysis measuring
outcomes of religious or spiritual therapies compared to traditional therapies found that the
inclusion of religion into therapy by way of Christian-accommodation cognitive therapy for
depression resulted in clients who had greater improvement both psychologically and spiritually
compared to those in traditional therapy (Worthington et al., 2010). Another spiritual-based
therapy that shows promising results for clients with depression is Mindfulness-
Based Cognitive Therapy that is specifically directed at depression, the use of which resulted in
clients showing a significant reduction in relapse of depression (Behrens & Terrill, 2011).
Westgate uses four dimensions of spiritual wellness, including meaning in life, intrinsic
values, transcendence, and community of shared values and support, to address the issue of
depression (1996). Some of the most well-documented feelings related to depression are feelings
of hopelessness and meaninglessness in life (Westgate, 1996). It follows then, that increasing
meaning of life should eliminate some feelings associated with depression. A study completed
by Richards, Owens, and Stein (1993) showed that there is significant improvement in
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depression when spirituality was added to group therapy (as cited in Westgate, 1996). Another
study, completed by Carson, Soeken, and Grimm (1988), found that feelings of life satisfaction
and life purpose were related to hope (as cited in Westgate, 1996). Further research regarding the
negative relationship between meaning in life and hope and depression is needed, however, it
seems promising that instilling hope and meaning in life will help clients with depression.
Although the relationship between intrinsic values and depression is still inconclusive,
there is a large body of research that shows that intrinsic values are related to high levels of
mental health (Westgate, 1996). Transcendence, which refers to one’s relationship to the
universe and creation, also needs further study to determine a negative correlation to depression,
although there is some evidence suggesting that such a relationship exists (Westgate, 1996).
Researchers have noticed that depressed persons often have a narcissistic preoccupation
(Westgate, 1996). Seligman (1990) has recognized an increase in depression in the United
States, which he believes is caused by an increasingly narcissistic society (as cited in Westgate,
1996). It is interesting to note that in the Amish community in Pennsylvania, a highly religious
community, the rate of depression is between one fifth and one tenth that of the non-Amish
population of the United States (Westgate, 1996). The last element of spiritual wellness,
community of shared values and support, is especially important for clients who are depressed.
Often, individuals who are depressed state that they feel a loss of emotional attachment, which
usually leads to withdrawal from social activities (Westgate, 1996). Many studies have linked
high levels of religious attendance to low levels of depression. One such study, completed by
Hertsgaard and Light (1984) found that women who attended a religious service at least once a
month had lower depression scores than their counterparts who did not attend a religious service
(as cited in Westgate, 1996).
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Spirituality, Religion, and Addictions Counseling
Addressing spiritual and religious issues in addictions counseling can be very beneficial
for the client. The CACREP addictions counseling standards include elements of spirituality,
emphasizing the importance of spirituality when one recovers from addiction, and the
importance of the counselor understanding the client’s spiritual history (Morgen, Morgan,
Cashwell, & Miller, 2010). Spirituality has also traditionally been addressed in Alcoholics
Anonymous’ 12 Step program that addresses the importance of hope, which can be a deeply
spiritual concept to many clients (Morgen et al., 2010).
Spiritual mindfulness techniques, such as Acceptance and Commitment Therapy have
been shown to be effective in treating clients with substance abuse (Behrens & Terrill, 2010).
Clients who participated in a week long study using Acceptance and Commitment Therapy
showed a decrease in internalized stigma, and in shame (Behrens & Terrill, 2010). Addictions
counselors looking to add spirituality to the counseling setting can benefit from using Spinelli’s
Existential-themed realms of descriptive inquiry to explore the client’s worldview (Morgen et al.,
2010). The four realms are I-focused, You-focused, and We-focused/They-focused (Morgen et
al., 2010). In the I-focused realm, the counselor explores the client’s spiritual beliefs and world
experiences (Morgen et al., 2010). The You-focused domain refers to how the client experiences
others spirituality and religion (Morgen et al., 2010). Finally the We-focused/They-focused
domains encompass the total experience between the counselor and the client in the present
moment as well as beyond the counseling session (Morgen et al., 2010). These four realms
embody the importance of counselor self-awareness, as well as understanding the client’s
worldview.
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Spirituality, Religion and Dying
As people age, they become more religious and/or spiritual, which is a normal
developmental process (Reiner, 2007). This is evidenced by a Gallup Poll from 2001 (Reiner,
2007). The poll found 60% of fifty to sixty-four-year-olds reported that religion was “very
important”, and when seventy-five-year-olds and greater were surveyed, that number jumped to
75% (Reiner, 2007). Therefore, clients who are terminally ill and at the end of their lives often
need their counselors to address elements of spirituality and/or religion.
It is important for those who are at the end of their lives to gain a sense of completion,
regardless of their beliefs or lack of beliefs (De La Lama & De La Lama, 2011). To become
competent, counselors need to understand death and the spiritual needs of the dying. One main
reason is that the process of dying, including long-term care, and the bereavement process, is
stressful and often spiritual for both the dying and the caregivers of the dying (Daneker & Smith,
2007). Understanding spirituality and dying is especially relevant currently, as the Baby Boomer
generation is aging, and many more people will have to face terminal illness and death than
before (Daneker & Smith, 2007). It is most important when working with those who are dying
to offer comprehensive care that addresses the whole person (Daneker & Smith, 2007).
According to Daneker and Smith, there are seven goals to meet to adequately provide
comprehensive spiritual care (2007). The seven goals are to provide culturally sensitive care, to
increase quality of life, to alleviate anxiety, to provide comfort and personal contact, to promote
meaning, significance, and hope, to promote informed decisions congruent with spiritual values,
and to increase caregiver confidence (Daneker & Smith, 2007).
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Counselors can provide culturally sensitive care to dying clients by exploring clients’
spiritual development, religious traditions, family values, and experiences of disillusionment
(Daneker & Smith, 2007). In some cases, clients may need to reconcile differences in personal
spirituality and religious upbringing (Daneker & Smith, 2007). Addressing quality of life through
spiritual care is an essential part of working with the dying (Daneker & smith, 2007). An
example of this would be when a client feels the need for confession, in which case it would
behoove the counselor to consult with the client’s spiritual leader so that the client can
participate in a culturally and religiously and/or spiritually appropriate ritual (Daneker & Smith,
2007). To help those who are dying alleviate anxiety, counselors can help them identify their
spiritual fears and concerns, and can provide the time to speak openly with them in an effort to
validate their concerns, and provide support (Daneker & Smith, 2007).
Counselors can best provide comfort and personal contact by offering a safe environment
for the client to contemplate spiritual aspects of the dying process, and often involves the
counselor bearing witness to the client’s story, paying particular attention to spiritual aspects
(Daneker & Smith, 2007). Narrative therapy is useful when working with clients who are dying,
as it encourages clients to tell their story, and can help them discover empowering, hopeful
storylines (De La Lama & De La Lama, 2011). Allowing clients to tell their story is also an
opportunity to help them to find meaning in their experiences (Daneker & Smith, 2007). It
allows clients to process the meaning of their death, and understand it in terms of a larger human
story, as well as instilling a sense of significance and legacy (Daneker & Smith, 2007). With
clients who are dying, counselors must consider decisions the client must make, and help those
decisions to be informed and congruent with spiritual values (Daneker & Smith, 2007). Such
decisions include advanced medical directives and medical powers of attorney (Daneker &
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Smith, 2007). By meeting the six aforementioned goals, and remaining present with the client,
counselors can increase caregiver confidence that their loved one’s spiritual needs are being
attended to all through the dying process (Daneker & Smith, 2007).
Limitations of Addressing Spirituality and Religion in Counseling
Spirituality and religion are important aspects of many Americans’ lives, and most clients
benefit from exploring such issues during the counseling process. However, there are some
situations where it is inappropriate to include spirituality and/or religion in session. It is
important for one to recognize his or her limitations when counseling (Cashwell & Young,
2011). When counselors encounter clients whose spiritual and /or religious values are extremely
different from their own, and they have consulted and done research, and still feel a lack of
knowledge that is impeding the counseling process, oftentimes it is best to refer the client to
someone who has more knowledge and expertise (Cashwell & Young, 2011).
As previously discussed, it is inappropriate to have too much religion or spirituality as an
intervention in the counseling session, as when the counselor begins to assume the role of a
religious leader (Cashwell & Young, 2011). An example would be a counselor who absolves a
client of sins, which would be more appropriate for a religious leader (Cashwell & Young,
2011). Over focusing on spirituality can have detrimental effects on the client as well, as it can
result in the client wanting to avoid work at all levels (Cashwell, Bentley, & Yarborough, 2007).
Some clients attempt to address problems exclusively and prematurely on the spiritual level,
ignoring other levels of healing, such as emotional, cognitive, or interpersonal levels (Cashwell
et al., 2007). When this happens, it is termed spiritual bypass, and it significantly hinders client
healing, as the client is avoiding genuine contact with his or her “unfinished business” (Cashwell
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et al., 2007). When spiritual bypass occurs, counselors should move towards healing the whole
person, by bringing attention to other areas that need healing, such as cognitions (Cashwell et al.,
2007).
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Conclusion
Although many counselor training programs often fail to adequately address how one
should approach spirituality and/or religion, it is important for counselors to address spiritual
and/or religious beliefs, or lack of beliefs, with clients. Having spiritual or religious beliefs is
beneficial to one’s health, as evidence by aforementioned research. It is also important for
counselors to recognize clients’ spirituality and/or religion as a strength that both the counselor
and the client can utilize during counseling. When counselors address spirituality and religion
with clients, it is imperative that counselors have a good understanding of what clients’ beliefs
are, and where on the spectrum of spirituality and religion they fall. However, before one begins
to explore the spiritual realm with clients, counselors must become competent in integrating
spirituality and religion into the counseling setting. Counselors can become competent by
studying and the fourteen ASERVIC competencies. Once one achieves competence with regard
to spirituality and religion, counselors can address such matters as they relate to many other
client concerns, such as depression, addiction, end of life issues, and many others. However it is
imperative that counselors are aware of their limitations so that they are not doing harm to the
client.
One limitation to this research is that there are many different definitions of the terms
“religion” and “spirituality”. Therefore, it is difficult to synthesize findings from different
studies, as there is no consistency with these terms. Another limitation is that there has
traditionally been a lack of training with regard to how to address spiritual and religions matters,
and much of the research is relatively new. Also, ASERVIC was only recently created, in 1995,
and it is still establishing itself. Therefore, professionals are still in the process of discovering
best practices and effective use of spirituality and/or religion in the counseling setting.
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Despite these limitations, the evidence strongly suggests that spirituality and/or religion is
beneficial to one’s well-being, and can be instrumental in the therapeutic counseling process.
Therefore it behooves counselors to remain informed of the current research, as much more is
sure to follow what already exists. This is especially true of research of best practices, which
needs a great deal of further research.
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