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Article 23

A Conceptual Model for Integrating Spirituality Into the Diagnosis and Counseling Treatment Plan

Kathleen R. Arveson

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A young couple, Sherry and Steve, come to see you for premarital counseling. In most every respect they seem ideal for one another. They communicate openly and respectfully, they have an understanding and appreciation of each other’s upbringing, and they have realistic expectations about marriage. Family and friends are positive and encouraging. When asked where the difficulty lies, Sherry states that in college she became a born-again Christian. Sherry says that it is vitally important to her that her husband have the same theological beliefs, and that he share her views concerning the roles of husband and wife. Steve explains that he is a spiritual person, but does not care for “organized religion.” He does not mind her involvement but chooses not to participate.

In this scenario, what is the role of the professional counselor? Does the counselor treat the couple the same as if it was, say, a financial problem—he is a spender and she is a saver? While every couple has their persistent issues, in Sherry and Steve’s case, their differences in worldview are of a higher magnitude than, say, a saver learning to live with a spender. For Sherry, the religious differences could very well be a deal breaker. It is important for the counselor,regardless of his or her personal beliefs, to establish rapport, develop a respectful connection to both parties, and use language which enables this couple to reach a decision or plan of action concerning their relationship.

The Problem of Integration Between Spirituality and Counseling

Why is the topic of spirituality or religion different from other issues? Why is it that many counselors can freely talk about sexual abuse, any number of addictions, or even suicide with their clients but hit a wall when it comes to the spiritual dimension? Bergin (1983) suggested that most psychologists, social workers, and mental heath providers have had no instruction in the role that religion plays in the lives of their clients. Frame (2003) pointed out six reasons for this omission: (1) the tenuous relationship between psychology and religion; (2) the conflict between the assumptions of the scientific world and those of religion and spirituality; (3) the association of religion and spirituality with pathology; (4) the belief that religion and spirituality are the prerogative of the clergy and other spiritual leaders; (5) a lack of training regarding how to integrate religion and spirituality into clinical practice; and (6) mental health practitioners’ own unresolved religious or spiritual issues. (p. 9)

In fact Bergin’s (1983) research has shown that over 77% of research studies indicate a positive or neutral relationship between religion and mental health. Furthermore, when more refined measures of religiosity are taken into account, it is possible for researchers to distinguish between healthy and unhealthy manifestations of religion. For example, Gartner, Larson, and Allen (1991) have shown that devoutness is associated with better physical health, social adjustment, and emotional well-being. Due to these and other research studies over the past 20 years, a lot more attention and study has been given to the impact of religion on mental and physical well-being. Organizations like the American Psychological Association and the American Counseling Association have designated divisions for the study of spirituality and religion. Furthermore, professional conferences are helping to educate mental health practitioners who may have not received information about the religious and spiritual dimension of human development in their counseling training.

Frequency of Religious Affiliation Worldwide

This omission and ignorance of the spiritual dimension is remarkable given the importance that faith plays in the lives of people worldwide and Americans in particular. According to Barrett (1996), people with a Christian worldview make up 33.7% of the world’s population. Jews are 0.2%, Muslims are 19.2%, Buddhists are 5.7%, Hindus are 13.7%, and a variety of other religions make up 9%. Atheists make up 3.8 % and nonreligious people represent 14.75% of the world population. Therefore, almost 80% of the world’s population is affiliated with some recognized religion. Many of the nonreligious perhaps consider themselves spiritual is some way since they do not consider themselves to be atheists. This leaves just under 4% of people who adhere to no religiosity or spirituality.

According to a 1997 poll of adults by the University of Michigan, 53% of Americans consider religion to be very important in their lives. This compares with 16% in Britain, 14% in France, and 13% in Germany. In the United States, 44% of adults report to going to church at least once a week.

Hart (2004) cautioned that spirituality means many things to many people. While Hart was encouraged that the mental health field is more open than ever to spirituality, he recommended that counselors be careful in using the term. As he put it, “almost every system, religious or not, claims to have a spiritual component. Every religion claims to have its spirituality, but so do New Age practices, naturalist spirituality, animism, witchcraft, feminist spirituality, and Twelve-Step programs” (p. 9).

Assessing Spirituality in Counseling

How does the secular counselor begin to assess the importance that spirituality plays in the life of his or her client? Richards and Bergin (2005) recommended conducting a short Religious-Spiritual Assessment during the intake interview. In their article, they included an example of a 12-question questionnaire which quickly covers a client’s religious history and current beliefs and practices. When a clinician takes the time to conduct a cursory evaluation, it will become clear whether spirituality plays a major or minor role in the client’s life. For many, this is the end of the spiritual exploration. Either the client expresses a nominal interest in religion or the issues the client wishes to discuss have no bearing upon spirituality. However, even for these clients, a time may come in the course of therapy when they do wish to refer to questions of belief. Because the counselor has taken time at the beginning of counseling to make spiritual queries, perhaps the client will feel that it is safe to discuss spiritual concerns with this counselor.

Other clients may be very relieved that the counselor has opened the door to spirituality. They may strongly feel that the issues they came to counseling to discuss affected their faith but did not know if it was permissible to discuss their faith with a counselor. When the counselor takes the first step, the client is put at ease.

When a client reveals that his or her spirituality plays a central part in his or her life and decision making, it is very helpful if the counselor has other tools to better assist the client to have a satisfactory counseling experience. For clients for whom religion is more central, Richards and Bergin (2005) suggested making a deeper religious assessment than the one used at intake. A deeper assessment allows the client to feel more fully understood and helps the counselor create a more empathic relationship. A fuller religious spiritual assessment can also assess whether a client’s spiritual orientation is operating as a healthy support in the client’s life or is contributing to the client’s pathology. Such an assessment can also reveal what other sources of support the client may have in the community in terms of clergy and fellowship groups. The counselor may also want to know what types of spiritual interventions would be meaningful for the client. Richards and Bergin (2005) suggested that a religious spiritual assessment may cover these nine areas: metaphysical worldview, religious affiliation, religious orthodoxy, religious problem-solving style, spiritual identity, God image, value-lifestyle congruence, doctrinal knowledge, and religious and spiritual health and maturity. Various surveys have been developed which can assist in this process.

Frame (2001) has adapted the genogram as a device that most counselors are familiar with to assess a client’s worldview. Frame (2002) suggested that the client create a genogram and add color for various denominations.

For example, Roman Catholics may be drawn in red, Protestants in orange, Jews in blue, Muslims in black, Mormons in gray, Buddhists in yellow, Unitarians in purple, agnostics or atheists in pink, personal spirituality in green, and no religious/ spiritual affiliation in brown. If religious/spiritual heritage is unknown, no color is added. (p. 110)

This color coding allows both counselor and client to see the differing streams of spirituality that have impacted the client’s life and the sources of beliefs and values. The use of the genogram to map spirituality can easily be incorporated into counselor training programs.

Spiritual Interventions

For the client who rates religion or spirituality as very significant, it is very likely that religious or spiritual interventions may be important in the treatment plan. While agreeing that psychology has too long ignored the very central role that religion plays in the lives of many people, most professional therapists who advocate including the religious dimension in therapy (McMinn, 1996; Moon, 1997; Tan, 1994, 2002) have emphasized that for a religious intervention to be a positive contribution in counseling, it should be practiced in a clinically sensitive, ethically responsible, and professionally competent way. McMinn (1996) cautioned therapists to exercise prudence in using any spiritual intervention as a part of psychotherapy. Tan (2002) further stated that therapists should not employ spiritual interventions in order to impose a specific religious tradition on clients but should always work within the client’s value system as far as possible. Counselors should always get written consent from the client and supervisor (when appropriate) prior to using spiritual or religious interventions, and parental permission if working with minors. There may be times when it would be advisable for the counselor to refer the client to a clergy person or other spiritual adviser. For instance, it may be helpful for a client to consult with his or her pastor what his or her particular community’s position is concerning divorce and remarriage.

Discussion of the client’s spiritual concerns should not completely replace psychotherapy in the therapy session. It is often more appropriate for the counselor to suggest a variety of interventions the client can do outside the counseling office. Certain therapeutic interventions that Richards and Bergin (2005) suggested therapists may recommend are prayer, contemplation and meditation, reading sacred writings, forgiveness and repentance, participation in worship, ritual, and fellowship and service. Outside of therapy, clients may also seek various forms of spiritual direction.

Often, a client who states that faith plays a very important role in his or her life will deliberately choose a therapist who shares his or her worldview. In such cases, spiritual interventions may be cautiously and sparingly used in the therapy session itself. As with any counseling relationship, genuineness on the part of the counselor matters more than the intervention itself. The counselor’s character matters far more than his or her technical training and theoretical orientation. The counselor who spends time developing a strong spiritual life and relationships with others outside the office will have the most profound impact on the client inside the office (McMinn, 1996).

In conclusion, while counseling training programs have become proficient in teaching students to be sensitive to multicultural concerns, most students need more training in world religions and spiritual integration strategies. An excellent start for counseling programs that do not include the spiritual dimension in their course work is to use the Richards and Bergin (2005) text A Spiritual Strategy for Counseling and Psychotherapy in their ethics or multicultural curriculum. This text is published by the American Psychological Association and also has an accompanying case book. Another suggestion is for currently practicing counselors to take continuing education units in spiritual integration to better counsel the population they serve.