Spirituality, Religion and Counselling Practice: A Guide to Competent Integration by Tyrell R. Arnold B.A., University ofLethbridge, 2007 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF EDUCATION IN COUNSELLING ~RSrrYofNORTHER~ BRITISH COLUMBIA LmRARY .PrinCe George, B.C. THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA March 2010 © Tyrell Arnold, 2010 II Table of Contents Table of Contents ................ ......... .................... ....... ..... .............................................. ... ................. ii List of Tables .......................................................... .... ................................................................... vi : List of Figures .............................................................................................................................. vii Acknowledgements ...................... ............................... ........ ....................................... .......... ... .... viii ... Dedication ..................................................................................................................................... ix Spirituality, Religion and Counselling Practice: A Guide to Competent Integration ..................... 1 Section 1: Religion, Spirituality and Counselling Practice: Rationale and Purpose of Guide ....... 1 ••••••• Section 2: Religion, Spirituality and Counselling Practice: Review of the Literature ................... 6 Defining Spirituality and Religion .................................................................................................. 6 Spirituality ............................................................................................................................... 7 Spiritual beliefs, practices and experiences ...................................................................... 11 Religion ................................................................................................................................. 12 Religiosity: Extrinsic, intrinsic and the like ...................................................................... 14 Religion vs. Spirituality ......................................................................................................... 17 Evidences for Religious and Spiritually Integrated Counselling ....... ............................. .............. 17 Explicit, Implicit and Intrapersonal Integration ................................ ................................... .. 18 Research Evidence ................................................................................................................ 19 Counsellor Reluctances ................. ...... ............... .................... .................. ............... ........ ... ... 23 Religion, Spirituality and Culture ......................................................................................... 25 Benefits of Clinical Integration ............................................................................................. 25 Prevalence of Religious and Spiritual Problems ................................................................... 27 '; 111 Educational Opportunities ............................................................................................................ 31 Ethical Implications ...................................................................................................................... 32 Conclusion ..................... ....... .... ................................... ........................ ... .......... ..... ............... ........ 36 Section 3: Religion, Spirituality and Counselling Practice: Guide to Clinician Responsibilities 37 Professional Competencies and Responsibility .................................................. .... ......... .... ..... ... 38 Belonging to a Faith Tradition ...... ........................ .......................... ............ .. .. ......... ...... ....... ..41 Counsellor Self-Awareness ............... ....... ................................. ... .. .................. ....................... 45 Personal Needs and Values ..................................................................................................... 45 Countertransference ....... ...... ......... ....... ........ .. .. .. .. .. ......................... .......................... ..... ...... ... 46 Blurred Boundaries and Dual Relationships ............... ..... ...... ...... .... .................. ............. .. ...... 54 Client Welfare ......... ................ ........... ............... ....... ........................... ...... ............................ ..... ... 55 Validating Aspects of Religiosity and Spirituality ... ...................... ......... ...... ...... ................. .. 56 Destructive Beliefs and Practices ............................................................................................ 58 Developmental Readiness ... ... ... ............................................ ... .......... .......... ... ........... ............. 63 Conclusion .............................. ................ .. ........................................ .......... ...... .......................... .. 66 Section 4. Religion, Spirituality and Counselling Practice: Guide to Therapeutic Techniques and Interventions ......... .................... ...... ................. .... .............. ..................................... ...... ................ 68 Counsellor Self-Assessment ...................................................... ................................ .. ................. 68 Recommended Activities ........................................................................................................ 69 Write a spiritual autobiography .................... .... .... .................... .......... ..................... ......... 70 Joumaling .............................................................. .... ... ... ..... ............ ................... .............. 72 Seek supervision and consultation ... .. .. .. ............................ ......... ................ ............. ......... 73 Spiritual Genograms ........................... ..... ........................... ......... ...... ... ......... .............. ..... 74 Consult competent professionals .................................. ........ .......... .......... ..... ........... ........ 79 lV Religious and Spiritual Assessment ooooo oooo oooooooooooooooooooo ooooooooooooooooooooooooo 0000000 00000000 000000000000000000000000081 Process Guidelines 00000000000000000000000000000000000000000000000000000000 0000 0000 0000 00000000 0000000000000000000000000000000000000083 Establish a therapeutic relationship ooooooo 0000000000000000000000000000000000 00000000000000000 0000 0000000000000000000083 Working within clients' framework oooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo84 Assessing Client Religious and Spiritual Needs 00000000000000000000000000000000000000000000000000000000000000000000085 Intake procedures 0000000000000000000000000000000 0000000 oooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo85 Assessment procedures ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo86 Qualitative assessment techniques oooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo89 Assessment questions 000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 0000000000000 000089 Spiritual genograms 000000000000000 0000000000 0000000000000000000000000 0000000000000000000000000000000000000000000000000000000090 Assessing formative influences ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo96 Quantitative Assessment Indexes and Scales OoOoooooooooOOoo oo oooooooooooooooooooo o000000000000000000000000000000000098 The spirituality scale oooooooooooooooooooooOOoooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo98 The index of core spiritual experiences 0000000000000000 00000000000000000000000 0000000000 0000000000000000000000000100 Spiritual well-being scale oooooooooooooooooooooooooooooooooooooooooooooo oooooooooooooooooooooooooooooooooooooooooooooooooo1 03 Spiritual health inventory 00Oo 000 00000000000000000000000000000000000000000000000000 00000000000000000000000000000000000 0000103 Spirituality assessment scale 0000000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000104 Other inventories 00000000000000000000000000000000000000000000000000 00000000000000000 0000000000000 00000000000000000000000000000105 Therapeutic Interventions 000 0000000000000000000000 00000000000000000000000000000000000000 00000000000000000000000000000 000000000000000107 Prayer oooooooooooooooooooooooooooooooooooooooooooooOOoooOOoooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo110 Meditation, Spiritual Relaxation and Imagery Techniques ooooooooooooooooooooooooooooooooooooooooooooooooool13 Spiritual Journaling oooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo ooooooooooooooooooooooooooooooo115 Reference to Scripture and Spiritual Text..oooooooooooooo ooooooooooooo ooooo oooo oooooooooooooooooooooooo ooooo oooooo oooo .l17 v Forgiveness ......... .... ............... .... ..................................... ........................................ .............. 118 Twelve-Step Programs .......................................................................................................... 119 Conclusion .. ........................ ......... ............ ....... ... ..... ........... ............. .................. .......................... 121 References ............... ........ ........... .......... ........................ .. .... ... ..... ..... .... .......... .............................. 123 Vl List of Tables Table 2.1 Definitions Offered on Spirituality ............................................................................... 9 Table 2.2 Degree of Religion and Spirituality ............................................................................. 16 Table 2.3 Educational and Training Opportunities ..................................................................... 32 Table 2.4 Guidelines for Working with Religious/Spiritual Clients ............................................ 35 Table 3.1 Religious and Spiritual Competencies ............ ...... ............................................. .... ..... .42 Table 3.2 Avoiding Values Imposition ...................................................................................... .46 Table 3.3 Potential Sources of Countertransference ...... .. ....... .................................. ... ... ..... ....... 51 Table 3.4 Indicators of Healthy and Unhealthy Religious and Spiritual Beliefs ........................ 61 Table 3.5 Fowler's Six Stages of Faith Development ................................................................ 65 Table 4.1 Proposed Autobiography Format ................................................................................ 71 Table 4.2 Joumaling Questions ................................................................................................... 73 Table 4.3 Spiritual Genogram Questions .................. ........ .......................................................... 76 Table 4.4 Interview Questions ........................................................................... ....... .................. 79 Table 4.5 Intake Questions Focusing on Religion and Spirituality ............................................ 87 Table 4.6 Culturally Sensitive Spiritual Genogram Questions for Native Americans .. ............. 94 Table 4.7 Assessing Formative Religious and Spiritual Influences ................... .......... .............. 99 Table 4.8 The Index of Core Spiritual Experiences (INSPIRIT) .............................................. 10 1 Table 4.9 Guidelines for Incorporating In-session Prayer ............................................ ........... . 113 Vll List of Figures Figure 4.1 Olivia's Spiritual Genogram ......... ............ .......................... ....................................... 78 Figure 4.2 Mary's Spiritual Genogram .... .......................... ... .... ... .. ........ ... .................................. 97 Vlll Acknowledgements First and foremost I would like to thank, with my deepest love, kindness, and respect my beautiful wife, BreAnn. She has valiantly stood by my side though the sweat and tears and joy and pain as I have worked diligently not only on this guide but though all my educational pursuits. BreAnn has worked just as hard if not harder than me so I could achieve my academic aspirations. She has not only sustained me but is also working hard to raise our three wonderful children. She is truly an inspiration to me. As I mentioned I have three beautiful, healthy children whom I love without end. Ashlyn, Tia and Quentin I love and appreciate their patience as I have been away time and time again and when I've been home being unavailable as I have been completing my degree. As each of them has come into our home they have deepened my love and understanding of the divine nature of our creation. My spiritual convictions have only deepened from each passing moment I have spent with them. I especially want to extend my deepest thanks and gratitude to my Project Supervisor, Dr. Linda O'Neill. She has unwaveringly helped and supported me in this immense task. She has always been very optimistic and encouraging, giving me timely responses and the best advice a supervisor can give. Thank you so much. Finally, my gratitude extends to my committee members, Dr. Corinne Koehn, who always provides pointed, meticulous and insightful suggestions and to Allan Whidden for being an enthusiastic and interested committee member. He has provided me with substantial insights and suggestions related to integrating religion and spirituality within counselling practice. IX Dedication This guide is dedicated to the spiritual being within each ofus. May we all find joy, peace happiness, and love in this life and in the life beyond. 1 Section 1. Religion, Spirituality and Counselling Practice: Rationale and Purpose of Guide Traditionally psychotherapy has resisted and in many cases ignored the integration of religion and spirituality in counselling practice. The struggle to find a balance between the absence or inclusion of religion and spirituality within counselling can be attributed to an array of principles, theories, traditions, trepidations and blatant hostilities. Despite what appeared to be an untenable challenge of reaching over the chasm of traditionalism, the counselling field is bridging the gap between conventional and contemporary psychological interventions with the integration of religion and spirituality into the counselling process. Integrating religious and spiritual issues is becoming more prominent in counselling practice and in the counsellor preparation process. It appears that maintaining a purely secular experience in counselling is archaic considering how fundamental spirituality and/or religion is in many clients' lived experience. As counsellors strive for a holistic view, they are more prone to integrate clients' religious and spiritual concerns in their counselling practice (Briggs & Rayle, 2005b). Not surprisingly, an explosion of research and academic journals and articles are now being devoted to the important field of integrating spirituality and religion in counselling practice. Even with growing evidence for the inclusion of religion and spirituality in counselling there are few comprehensive guides for practitioners detailing how to integrate spirituality and religion in counselling practice and in counsellor training programs. This guide answers the following questions: Why is integrating religion and spirituality in counselling practice important? What can counsellors do to become competent in integrating clients' religious and spiritual perspectives? When is it appropriate for counsellors to incorporate religion and 2 spirituality with clients? How do clinicians then approach the subject of religion and spirituality with clients? And who should initiate consideration of religious or spiritual concerns and interventions during therapy? These are all questions I believe are important to examine and have informed answers for. In lieu of these questions, this guide offers valuable information and insight into the integration of religion and spirituality with counselling practice. I am optimistic that this guide will be of worth not only to practicing clinicians but also to counsellor educators and their students. The guide is based on the premise that religious and/or spiritual issues are important for most clients. A holistic view of clients' lives can only be achieved by bearing in mind each client's spiritual and/or religious views, which are for many people the fundamental facet of their being. In other words, to cultivate clients' complete health and well-being, counsellors should be willing to form a marriage between secular counselling practice with clients' religious and spiritual experiences and concerns. Many counsellors have reservations about addressing religious/spiritual issues within the therapeutic relationship. This is largely because topics such as religion, spirituality and related terms like sacred, transcendence and trans personal are not often viewed as value-free terms (Lines, 2006). Through this guide I hope readers will be motivated to integrated religion and spirituality and query more into this therapeutic landscape, seeking to find other ways they can integrate religion and spirituality into their counselling practice. The purpose of this guide is to: (1) help explore the connection that exists between secular counselling and spiritual issues that can and should be addressed in counselling practice; (2) provide a guide to practitioners on how they can confidently integrate religion and spirituality 3 into their counselling practice; and (3) integrate throughout the guide ethical guidelines that should be considered. This guide will by no means replace existing works on integrating religion and spirituality with counselling but will hopefully add to the distinguished contributions already advanced in this area. Although the guide will incorporate conventional counselling practices with contemporary religious and spiritual counselling practices, its primary goal will be to help foster client welfare. This guide will not only allow practitioners to identify when spirituallybased interventions would be appropriate to use, but the guide will also enable clinicians to assist their clients in processing, interpreting and integrating important aspects of their religious and/or spirituality within the counselling context. Additionally, this guide should stimulate individual counsellors to reflect on their own beliefs about religion and spirituality within the counselling context as part of continuous selfreflection to discover their own biases and beliefs and enhance their clinical competencies. Most of all, this guide provides clinicians with a starting point to integrating religion and spirituality within their practice. This guide may stimulate counsellors to debate issues raised here and related issues in the larger hope of working toward a greater understanding and consensus on integrating religion and spirituality. I believe this orientation can enhance all counsellors' multicultural sensitivity and therapeutic efficacy with the large number of clients who approach life from a religious and/or spiritual perspective. Integrating religion and spirituality in counselling may be a new concept for some. For others, this may not be new but they have never really taken the opportunity to integrate religion and spirituality in their clinical practice. Yet others may hesitate in integrating religion and 4 spirituality in counselling or even feel that such integration is unnecessary. Nonetheless, there some who are currently approaching and integrating clients' religion and spirituality in counselling practice and these are the individuals we can tum to for competency. Consider the following clinical case illustration and ponder the questions it potentially raises. Clinical case illustration. You are conducting family therapy with a Native American mother who firmly believes in traditional spiritual practices and her rebellious teenage daughter who refuses to participate in ceremonial activities, Elder's teachings/guidance, and is struggling with cultural connection and cultural awareness. This is particularly problematic to the mother because she is aware of the generational trauma her family has faced and sees reconnecting with traditional beliefs a positive influence in her family's life. Although this issue partially reflects the daughters individuation from her mother, clear differences exist in your clients' spiritual beliefs. Would you feel competent to work with this family? What, if any, religious/spiritual-informed psychotherapy interventions might be appropriate? What role, if any, might your own religious or spiritual beliefs play in your therapeutic approach? Would you seek religious or spiritually informed consultation from colleagues to ensure that you provided competent service? Would you hesitate to approach the spiritual issue even though you believe it would be important in treating this family? These are all questions clinicians like you may be wondering about. In an advanced counselling course I participated in recently, the question was posed: "Do you incorporate religion and spirituality in counselling sessions if the client's problems appear to be linked to their religious or spiritual beliefs?" I was surprised by my cohort's responses. Some did not 5 know how to respond. Others claimed indifference and shrugged off their response. Others responded that religion and spiritual matters did not belong in clinical practice. From what I have read in the literature, these reactions are typical of most clinicians. But are these responses the most helpful and appropriate when it comes to client's religiosity and/or spirituality? I hope this guide will provide answers to counsellors' questions and concerns, and provide examples of appropriate interventions. As such I have developed this guide to aid clinicians as they integrate religion and spirituality in counselling practice. This guide is laid out in four sections. Section one, which you just read provides a general overview of the scope of the issues presented. Specifically it describes the rationale and purpose for creating a guide that advocates for integrating religion and spirituality in counselling practice. Section two provides literature relative to the progress already made in advancing religion and spirituality with counselling. Section three provides valuable information relative to counsellor responsibilities; this includes counsellor competencies, ethical considerations and ensuring client welfare is first and foremost upheld. The final section of this guide includes the meat and potatoes, ifyou will, of this guide. It specifically illuminates ways counsellors can assess not only clients' religious and spiritual views but also their own. This section further offers several therapeutic techniques that can be applied to religious and spiritual clients. 6 Section 2: Religion, Spirituality and Counselling Practice: Review of the Literature Spirituality is an integral part of a person's life. Everyone is looking for meaning in life which comes from the spiritual dimension of one's life. Many people have questions and struggles with [religion and] spirituality, which they bring to counselling. (Burke, as cited in Miller, 1999, p.499) Integrating religion and spirituality in counselling practice is becoming more prominent in the literature. The purpose of this literature review is to first describe and define spirituality and religion. Secondly, some of the reviewed literature demonstrates how relevant incorporating religion and spirituality into the therapeutic relationship is. Third, I will provide ample research evidence for an integrated counselling perspective that includes issues of religion and spirituality. The reviewed literature will also help me demonstrate the need for a guide that helps clinicians incorporate religion and spirituality in their counselling practice. Defining Spirituality and Religion Spirituality and religion continue to be controversial topics in part because of the challenge in defining these terms and determining how best to approach these domains within the context of client issues (Cashwell & Young, 2005b ). As such, adequately defining spirituality and religion is critical. This integration is not only imperative for counsellor's professional practice but can also be helpful in providing related psychoeducational material and insight to clients. Although spirituality and religion overlap and are analogous in many regards, they are not identical. It is not uncommon for individuals to profess to be spiritual and yet not religious. As a further illustration, when individuals refer to themselves as spiritual but not religious, they often mean they are not affiliated with an organized religion, but they do feel connected with 7 God or other sacred things. Similarly, spirituality may look very different from one individual to another. And yet others who are religious are not necessarily spiritual. It appears that many professionals and lay persons alike have tried to put these terms in a neat pigeonhole. For instance, Richard and Bergin (2005) offer several observations: (1) individuals tend to defme religion narrowly and spirituality broadly; (2) individuals are more likely to polarize and separate religion and spirituality; (3) professionals and lay persons alike tend to define religion as external, institutional, stagnant and substantive, and spirituality as private, relational, dynamic and functional; and (4) many individuals tend to view religion negatively and spirituality positively. This narrow perspective can lead to a limited understanding of spirituality and religion. In truth, defining spirituality and religion could fill volumes and is hence beyond the scope of this guide. Within the parameters of this guide, I simply define and describe these terms as they apply to integrating spirituality and religion in counselling. I contend, as Richard and Bergin (2005) do, that it is a serious mistake to simplistically view religion as "negative" and spirituality as "positive." By no means can these two terms be stripped down to such narrow views. Polarizing or completely differentiating spirituality and religion tends to generalize and warp their meaning. Spirituality and religion have many shared meanings and similar characteristics, representing a great deal of overlap as suggested; nevertheless, their differences need to be acknowledged. Spirituality We are what we think. All that we are arises with our thoughts. With our thoughts, we make our world. Buddha 8 Defining spirituality is no small task. One of the challenges of defining spirituality within the counselling profession has been the variety of definitions available. This may be due in part to our own limits on language. Greggain (2009) suggests that much of the disagreement and confusion in defining spirituality comes from trying to define something that may be indescribable. I believe spirituality is universal (i.e., all beings are spiritual); however, spirituality is very personal but is also developmental and may be sought for collectively (Cashwell & Young, 2005b). For example, parishioners may worship together for religious purposes but may also join together to develop their spirituality. Individuals tend to define spirituality from a perspective consistent with their spiritual maturity. This maturity is evident as people are all at various levels of spiritual development. Spirituality is not dichotomous-it is not an attribute that is either present or absent in an individual. Definitions of spirituality vary significantly. Some definitions are tied specifically to a belief in God or a transcendent being, while others refer to spirituality as a connection to nature and beauty (Carson et al., 2002). According to Welsh (1998) spirituality involves an active investment in an inner set ofvalues. This leads to a sense of meaning, inner fullness, and the development of bonds with others. This suggests that spirituality invites an increase of consciousness, with personal accountability beyond oneself. There are perhaps four main elements individuals use to describe and define spirituality: (a) finding meaning in life or a sense of direction; (b) living according to an inner value system; (c) believing in a higher power; and (d) participating in a community of people who share similar values and beliefs (e.g., a church parish or meditation group, healing circle, etc.; Curtis & Davis, 1999). There are a number of definitions that have been offered in counselling literature in an 9 effort to define and describe spirituality based on these four principles; Table 2.1 reviews several of these definitions. Table 2.1 Definitions Offered on Spirituality • "Perhaps the easiest distinction is to think of spirituality as a person's sense of meaning and purpose in life, or one's relation to the Cosmos" (Burton & Bosek, 2000, p. 98). • "Spirituality[ ... ] pertains to ultimate meaning and purpose in life" (Post, Puchalski & Larson, 2000, p. 578). • "Being spiritual suggests a personal commitment to a process of inner development that engages us in our totality .... Spirituality is a way of life that affects and includes every moment of existence. It is at once contemplative attitude, a disposition to a life of depth, and the search for ultimate meaning, direction, and belonging. The spiritual person is committed to growth as an essential ongoing life goal. To be spiritual requires us to stand on our own two feet while being nurtured and supported by our tradition, if we are fortunate enough to have one" (Teasdale, 2000, p. 17 -18). • An "invisible phenomena associated with thoughts and feelings of enlightenment, vision, harmony with truth, transcendence, and oneness with God" (Richards & Bergin, 2005, p. 22). • The "inclination or desire for a relationship with the transcendent or God" (Curtis & Davis, 1999, p. 3). Each of these definitions taps into a portion of spirituality but there are still limits. Post et al. 's (2000) definition, for example, is very vague, leaving much to be interpreted. Conversely, the definition proposed by Teasdale (2000) offers more breadth but implies that in order to be developing spiritually one must be actively seeking spiritual development-this may not always be true. Yet, Teasdale offers an important insight; one's definition of spirituality is typically bound by culture. Factors such as geography, age, gender, ethnicity, and health, according to Miller (2005), influence one's spirituality and spiritual development in a "complicated, interactive manner" (p. 105). 10 One of the misfortunes of using a fixed definition is in attempting to define spirituality in a single linear dimension (e.g. , something one has more or less of) is an oversimplification. Evidence suggests an operational definition of spirituality is one that can be used to characterize all individuals, regardless of their belief system (Miller & Thoresen, 2003). According to Myers and Williard (2003) this definition must be understandable and useful for counsellors; a definition that is inclusive of any particular orientation. For purposes of this guide I will use the spiritual definition provided by the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC, 1998): Spirit may be defined as the animating life force, represented by such images as breath, wind, vigor, and courage. Spirituality is the drawing out and infusion of spirit in one's life. It is experienced as an active and passive process. Spirituality is also defined as a capacity and tendency that is innate and unique to all persons. This spiritual tendency moves the individual toward knowledge, love, meaning, peace, hope, transcendence, connectedness, compassion, wellness, and wholeness. Spirituality includes one's capacity for creativity, growth, and the development of a value system. Spirituality encompasses a variety of phenomena, including experiences, beliefs, and practices. Spirituality is approached from a variety of perspectives, including psychospiritual, religious, and transpersonal. While spirituality is usually expressed through culture, it both precedes and transcends culture. (p. 3-4) It is obvious that defining spirituality is not a simple task; this definition includes a plethora of ideas and perspectives. But as this definition denotes, spirituality includes one's awareness, beliefs, values, sense of purpose and mission, subjective experience, and one's attempts to achieve something beyond the self. It could be said that this definition captures both 11 the exoteric- the communal facet of spirituality-and the esoteric- the private facet-of ones spiritual life (Faiver, O'Brien, & Ingersoll, 2000). This definition seems more inclusive, encompassing and clearer than many found in the literature. Spiritual beliefs, practices and experiences. Beyond defining spirituality, it may be beneficial to distinguish between spiritual beliefs, spiritual practices and spiritual experiences. Spirituality involves personal beliefs, such as those about a definitive human state or set of morals toward which one strives, a Supreme Being, or harmony with nature or universe (Walsh, 1998). Richards and Bergin (2005) explain that the question "Are you a spiritual person?" typically only opens a discussion about the person's belief system. Considering one's spiritual beliefs is only one aspect of one ' s spirituality. Spiritual practices refer to the dad-to-day activities one engages in that give rise to one ' s spiritual experiences (Richard & Bergin, 2005). As such, spiritual experiences may be holy or mystical; as Walsh (1998) explains spiritual experiences can be hard to characterize or explicate in common language and imagery. As one considers the interaction of spiritual beliefs, practices and experiences, then and only then can one's true spirituality come into focus. The relationship between spiritual beliefs, practices and experiences, on the one hand, are logical extensions of each other. For example, Rachel describes herself as a spiritual person belonging to no organized religion; however, Rachel values contemplative practices. She has studied meditative Buddhism and practices several meditative exercises each day. Over time, she has come into contact with a range of emotions that were previously unavailable to her. Consistent with her practices she allows herself to fully experience these new emotions and integrates them into her meditative practices, allowing her to become more spiritual in her beliefs, practices and experiences. 12 For others, the connection between beliefs systems, spiritual practices and spiritual experiences may be more fluid. Consider the following examples: • Greg was baptized in the Catholic Church as an infant and has participated in weekly Mass for most of his life out of a sense of obligation that he should attend. Because of this sense of obligation-and fear of what might happen if he does not attend-Greg has virtually no spiritual experiences and adheres to no disciplined spiritual practices outside of weekly Mass. • Lynn is an undergrad student who has become very interested in religion and has taken advanced courses on major world religions. However, Lynn has no spiritual practices to promote her spiritual development and had no occasions for spiritual experience. • Sheldon engages in spiritual cupidity by frequently exchanging one spiritual practice for another, "spiritual window-shopping" (Cashwell & Young, 2005b, p. 5) if you will for a transcendent experience. Engaging in this practice, however, is neither grounded in a set of spiritual beliefs nor in a persistent or disciplined spiritual practice. To be clear, when I use the term spirituality in this guide, I am referring to intangible phenomena that are associated with thoughts and feelings of illumination, images, agreement with truth, transcendence, and oneness with God (Richards & Bergin, 2005). One's spiritual experience may or may not include a deity. Religion The whole purpose of religion is to facilitate love and compassion, patience, tolerance, humility, forgiveness. Dalai Lama 13 Religion has been thought to encompass the ideas and characteristics of spirituality; however, there are important differences. As such, religion needs to be defined separate from spirituality (Cashwell & Young, 2005b; Steen et al., 2006). Whereas spirituality is a broad concept representing personal beliefs and values, religion tends to be a narrow concept that refers to institutional beliefs and behaviours (Myers & Williard, 2003). Miller and Thoresen (2003), for example, define religions as social entities or institutions which are distinct through their boundaries. Religion is differentiated by specific beliefs or practices, requirements for membership, and modes of social organization. Teasdale (2000) suggests, however, that religion is one way many people are spiritual. He states, "Often, when authentic faith embodies an individual's spirituality the religious and spiritual coincide. Still not every religious person is spiritual (although they ought to be) and not every spiritual person is religious" (Teasdale, 2000, p. 17). Religion has been defined by Geertz (1973) as "a system of symbols which acts to establish powerful, persuasive, and long-lasting moods and motivations by formulating conceptions of a general order of existence and clothing these conceptions such as aura of factuality that the moods and motivations seem uniquely realistic" (p. 90). Religion can be thought of or understood as organized spirituality that includes doctrines, prescribed rituals, and governing organization. In other words, religion can be seen as encircling or being encircled by spirituality (Steen et al., 2006). However, this does not adequately describe religion. Just as one does not need to be religious to be spiritual neither does one need to be spiritual to be religious (Curtis & Davis, 1999). It appears there are two main divisions of religion-exoteric and esoteric. An individual who practices exoteric religion focus their attention on the public, concrete, outer forms or doctrine of a religion. Those practicing religion 14 from an esoteric perspective focus on the personal experiences of the Divine reality (Faiver et al., 2000). Religiosity: Extrinsic, intrinsic and the like. The quality ofbeing religious is described as religiosity and one ' s religiosity may be extrinsic or intrinsic. On the one hand, extrinsic religious orientations are beliefs that are self-serving, used more for socializations and selfjustification, including explanations for existential dilemmas, security, and acceptance into a community. These individuals are spiritually immature and those with this orientation use religion for personal gains (Burton & Bosek, 2000; Faiver, et al., 2000; Weld & Ericksen, 2007). Extrinsic believers are apt to hold their faith informally and adjust or selectively apply it to meet personal desires. Basham and O'Connor (2005) provide a good example of an extrinsic orientation: "The faithful church goer who makes business contacts through church socializing, gains status in the church from teaching classes or holding a leadership position, and gains public credibility in the presentation of his moral, good citizen persona" (p. 147). Basham and O'Connor warn that extrinsic religious persons can be genuine in their religiosity and should not be mistaken as being fake or insincere. Simply stated religiosity is a part of these people's life because it benefits them, even though good often comes from their religiosity. On the other hand, intrinsic religiosity involves the internalization of beliefs and living them daily with commitment (Burton & Bosek, 2000; Hickson, Housley & Wages, 2000). Faiver et al. (2000) explain that this course is one focused on a genuine dedication central to the person's being. This in tum guides daily decisions and behaviours; these definitely held morals are integrated in a continuing valuation of one's spiritual commitment and personal development. The intrinsically devout person does not just believe his or her faith tradition; he or she lives the faith as the dominant motive of life. Consider, for example, the individual who is 15 monetarily prosperous but, in difference to society's material ideals, lives humbly and well within one's means. This type of person may also give a significant amount of their income anonymously to help ease the poverty and pain of others. Basham and O'Connor (2005) provide another excellent example of intrinsic religiosity. They explain that the man who is sorrowful over an error in judgment from hurting another person's feelings will, motivated to examine themselves and what they did wrong, correct their actions not out of embarrassment for making the mistake or by fear of other's perceptions, but through sincere sadness for harming another person. One's religiosity could be further described as pro-religious- which includes those who may be seen as both extrinsic and intrinsic in their religious beliefs-or nonreligious which include those who are low in both extrinsic and intrinsic religious beliefs (Smith & Orlinsky, 2004). This type of individual may be similar to an individual with a quest orientation (Cashwell & Young, 2005). These individuals approach existential questions without endeavoring to simplify them or to attain definitive conclusions. Instead these individuals feel that they will never fully comprehend the answers oflife's most significant questions and yet they are often unwilling to accept responses that seem unpretentious, dualistic, or too easy. Grasping the difference between these religious orientations can be helpful as religious beliefs can impact mental health. Basham and O'Connor (2005) and Briggs and Rayle (2005b) describe eight categories that show the amount in which religion and spirituality are central to clients' lives. It is important to understand which of these overlapping categories best describes one's clients as this provides clinicians with an awareness of how to integrate religious and spiritual beliefs. Table 2.2 represents a summary of these eight categories as described by the aforementioned authors. 16 Table 2.2 Degree of Religion and Spirituality Religious orientation Brief description Religiously committed clients Have intensely held beliefs about their religious views-this belief system is similar to an intrinsic orientation. These beliefs form one's attitude and act as a basis for one's morals that are used to make judgments and guide behaviour. Religiously loyal clients Have religious beliefs that emerge from their family history and/or cultural origins. Although these individuals typically keep their traditions faithfully, the application of these religious beliefs to personal growth and problem solving may or may not occur. Spiritually committed clients Have no organized religious affiliation, but are willing to look within, having a sense of belonging to the cosmos. Further having an awareness of connectedness to the divine, and an unselfish desire to help create a healthier world. Spiritual/religious open clients Belong to no religious tradition but are interested in the spiritual dimension as a path to problem solving and personal growth-this is similar to an extrinsic religious orientation. Superficially religious clients They are outwardly religious: however, their religious expressions lack inner conviction and have little or no impact on personal morals, philosophy or behaviours. Religiously tolerant and indifferent clients They are accepting of others religious and spiritual beliefs and practices but have no interest in participating or implementing such beliefs in their own lives N onspiri tual/nonreligious clients They purposefully reject all religious and spiritual beliefs contending such beliefs false and not essential for living well and understanding life. Notably, they are not necessary hostile toward those who profess religious or spiritual beliefs. Religiously hostile clients They not only reject religion but openly oppose religion, religious groups, and particularly the impact of religion on society. (Basham & O'Connor, 2005, p.l48; Briggs & Rayle, 2005b, p. 9192) 17 Religion vs. Spirituality Turner et al. (1995) viewed religion and spirituality both as involving a sense of meaning and purpose in life, thereby providing a source of love and relatedness, intended to keep believers in a "right relationship with the unknown and unknowable" (p. 436). Stanard et al. (2000) denote that there is no clear consensus in the literature on the existence or nature of the boundaries between religion and spirituality. Although I have previously presented definitions of spirituality and religion, there needs to be a clear distinction made between the two terms. Perhaps the best way to distinguish between spirituality and religion is this: spirituality is a more subjective experience, while religion is more objective with a set of beliefs or doctrines that are institutionalized (Stanard et al., 2000), even though both involve the sacrosanct. The Dalai Lama (as cited in Corey, 2001) teaches that religious beliefs are but one level or spirituality, making reference to basic spiritual values. These include qualities of goodness, kindness, love, compassion, tolerance, forgiveness, human warmth, and caring. Conversely, spirituality can be experienced either within or without formal religious structure. Some adhere to religious rituals, for example, without finding spiritual meaning in them. Welsh ( 1998) explains that still others reject ceremonial religion, yet discover spirituality in daily life. In seeking to find the common denominator between religion and spirituality, Hill and Pargament (2003) show that the sacred links religion and spirituality as it is sought for by both religious and spiritual people. Evidences for Religious and Spiritually Integrated Counselling Spirituality is a human need; it is too important to be misunderstood; avoided; or viewed as regressive, neurotic, or pathological in nature. Clinicians must recognize that a person's 18 spiritual beliefs, values, perceptions, feelings, and ideas, are intrinsically connected to religious, philosophical, cultural, ethnic, and life experiences. It is important that practitioners acknowledge that spirituality in a person's life can be a constructive way offacing life's difficulties. (Sermabeikian, 1994, p. 181) Explicit, Implicit and Intrapersonal Integration Counsellors and researchers have proposed several different methods of integrating religious and spirituality in counselling. One the one hand explicit integration refers to an overt approach that directly and systematically deals with religious and spiritual issues in counselling (Walker et al., 2004). This approach uses spiritual and religious resources like prayer, scripture or sacred texts, meditation, forgiveness, referrals to church or other religious groups, and other religious and spiritual practices. This approach emphasizes both therapist and client religiosity and spirituality and integrates some form of spiritual direction into counselling. On the other hand the implicit integration of religion and spirituality takes on a covert form. Where explicit integration is direct and systematic, implicit integration neither initiates the discussion of religious or spiritual issues nor openly, directly or systematically uses religious or spiritual resources in therapy. Walker et al. (2004) provide an example of how clinicians may implicitly integrate religion and spirituality in counselling; "implicit integration is based on therapeutic values on theistic principles from an organized religion [or spiritual orientation]. Implicit integration may be the preferred mode of integration for therapists who profess a religious faith or engage in spiritual practices but who are not trained in the explicit integration of religion and spirituality" (pg. 71 ). 19 Jntrapersonal integration may be considered a third form of integration. Intra personal integration refers to the manner in which a counsellor uses his or her own religious or spiritual experiences in counselling (Walker et al., 2004). Silently praying for a client during counselling, for instance, is one example of intrapersonal integration. According to Walker et al. (2004) most religious and spiritual integration in counselling occurs through this medium as a result of clinicians ' own experiences. Today there is a great need for clinicians to become explicit in integrating religion and spirituality in professional practice as many clients find strength through their religious and spiritual beliefs. This does not mean that clinicians need to ascribe to any particular religious or spiritual orientation but they should be willing to integrate religious and spiritual issues as appropriate. Research Evidence Integrating religion and spirituality within counselling is important as religion/spirituality are fundamental aspects of many clients' lives. Miller (1999) postulates that including religion and spirituality in counselling is not only beneficial, but is also necessary for many clients. Frequently clients are concerned about religious/spiritual issues in their lives and want to discuss these issues during the counselling process. Most Americans, for example, acknowledge belief in God or a higher power (95%), are affiliated with a church or synagogue (69%), or confirm that religion plays a considerable function in their lives (85%) (Frazier & Hansen, 2009; Gallup & Lindsay, 1999). In fact, Gallup and Lindsay (1999), who conduct national polls across the United States and whose polls are published by news media (CNN, USA Today, the Chicago Tribune Newspaper Syndicate, etc.), found that 9 out of 10 people report that they pray, with a vast majority (67%-75%) of people praying on a regular basis. In another study Burton and Bosek (2000) report that 77% of patients want spiritual issues discussed as part of their care. These 20 findings may be generalized to others around the world (Plante, 2007). In Canada, for example, through the 2001 Census, nearly 90% of the population indicated they were religious in some form, with 80% of these indicating some form of Judea-Christian orientation (Statistics Canada, 2002). Despite these findings, for decades the majority of counselling professionals had remained aloof from any religious/spiritual discussions or interventions with clients. Powers (2005) found, for instance, thorough an extensive review of academic articles, books, and book chapters that very little was published about religion/spirituality and counselling until the 1950s. In fact, it was not until the 1970s that publications related to spirituality noticeably increased; this increase continues today, reflecting the development of a new attitude about the counselling process and the inclusion of religion/spirituality. The separation of religion/spirituality from counselling until recently seems incongruent as such a large body of research provides ample evidence that all aspects of clients' lives influence their psychological wellbeing (Miller & Thoresen, 2003). Just as geographical culture influences, ethnic heritage or our familial genetics and environment influence us, so too, our religious and spiritual orientations and heritage influence who we are. In a recent study conducted by Frazier and Hansen (2009), religious and spiritual psychotherapeutic behaviours and their perceived importance were assessed. This study provides not only a baseline for integrating religion and spirituality in counselling but also illustrates that there is a large gap between the recommendations made in the clinical literature and between what practitioners actually do. In this study, the authors found that the practitioners who most frequently practiced interventions were: (a) actively communicating respect for clients' religious/spiritual beliefs; (b) actively seeking client feedback about services provided; (c) 21 promoting autonomy and self-determination of highly religious clients, even when their values differ from one's own; (d) use clients' religious/spiritual strengths in treatment; and (e) selfassess one's competence to counsel clients regarding religious/spiritual issues (Frazier & - Hansen, 2009, p. 84). Not surprising, the authors further reported that these items (excluding item [d]) were considered the most important for competent practice. Frazier and Hansen's (2009) study also found several religious/spiritual practices that clinicians rarely observe. These items include, (a) using prayer as a therapeutic intervention; (b) citing religious texts in treatment; or (c) actively seeking feedback on one's own religious/spiritual competence from colleagues. The authors conclude that we as counsellors need to be willing to integrate required religious/spiritual interventions with our clients. They suggest that this consideration will lead to effective, sensitive, and more appropriate psychotherapy. It appears that most counsellors believe that valuing clients' religious/spiritual beliefs is important, however, integrating those beliefs, practices and experiences in psychotherapy rarely happens. I have discussed Frazier and Hansen's (2009) study in order to argue that much needs to be done in the counselling profession regarding the integration of religion/spirituality with competent counselling practice. Young, Frame, and Cashwell (2007) provide the main premise for my argument: they suggest that training opportunities to help counsellors understand conceptual models, intervention techniques, and research findings that offer more direction for competent integration of religion/spirituality in their professional practice, must be extended beyond self-awareness components. I suggest in order for these things to take place (i.e., training of religious/spiritual conceptual models, intervention techniques, and research evidence) 22 we as counsellors need to be willing to step away from the traditional secular counselling models to more holistic orientations within the counselling relationship. Ignoring clients ' religious/spiritual beliefs, according to Curtis and Davis (1999), can diminish the effectiveness of counselling and lead to premature termination. Morrow, Worthington, and McCullough ( 1993) found in their study that clients whose religious and spiritual values and beliefs were supported by their counsellor were thought to improve more than the clients whose values were challenged. In another study Carlson et al. (2002) recapitulate the results of their study of 153 marriage and family counsellors as follows : "While 95% of the respondents believed there is a relationship between spirituality and mental health, only 62% believed that a spiritual dimension should be considered in clinical practice, and .. .47% agreed it is necessary to address a client' s spirituality in order to help them" (p. 166). In an earlier study, Propst (1980) found that religious clients suffering from mild depression benefited more from a religious imagery treatment than from a secular imagery treatment. There are indications that many religious people mistrust secular (nonreligious) counsellors which may lead to early termination. Slife and Richards (200 1) explain that religious people often seek aid from their own clergy rather than from professional counsellors. They further argue that when religious clients are willing to work with secular counsellors, it is often a major therapeutic challenge for such counsellors to create a relationship of trust and credibility. This is typically the case because many clients are concerned that their religious or spiritual perspectives will be discounted, ignored, or even viewed as pathological (Watts, 2001). Research indicates that by neglecting to draw on clients' religious and spiritual values, counsellors quickly lose the fundamental nature of their clients and deny them the opportunity to find meaning, strength, and support in their lives (Benjamin & Looby, 1998). 23 Counsellor Reluctance Historically, religion and spirituality have been excluded from the field of psychology. A major reason for this omission, according to Wolf and Stevens (200 1), is that from its inception psychology has endeavored to differentiate itself as a scientific domain. Importance has habitually been placed on the empirical and observable. Religion and spirituality have routinely been dismissed as "unquantifiable, mysterious aspects of human life" (Frame, 1996, p. 300). Other barriers have been discussed; for instance, assumptions that religious and spiritual issues should be discussed with spiritual or ecclesiastical leaders or that in the field's historical stance, religion and spirituality were more closely related to pathology than to health (Wolf & Stevens, 2001). Virtually all counsellors will encounter clients' religious and/or spiritual issues in their careers. Yet, most have little training in addressing religious and spiritual issues in clinical practice. In a survey of Association of Psychological Internship Centers training directors, 83% reported that discussions of religious and spiritual issues in training rarely or never occurred. An alarming amount of the study's participants (100%) indicated they had received no education or training in religious or spiritual issues during their formal placement (Lukoff et al., 1998). Another study of AP A member psychologists found that 85% reported rarely or never having discussed religion and spiritual issues during their own training. Shafranske and Malony (1990) found that 66% of psychologists surveyed in their study felt incompetent to counsel clients regarding religious and spiritual issues. Given these findings it is not surprising to see such reluctance in clinicians. Evidence suggests that the majority of clinicians are affiliated with a religious denomination but are largely inactive within organized religion (Helminiak, 2001; Shafranske & 24 Malony, 1990). Ironically, the majority of clinicians in one study claimed that spirituality is relevant to them but most rarely engage is personal spiritual practices (Walker et al., 2004). This in part may be related to clinicians' reluctance to integrate religious and spiritual practices as they may assume they cannot relate to religious or spiritual clients. In addition to obstacles involved with integrating religion and spiritual issues in clinical practice, Wolf and Stevens (200 1) suggest there are potentially negative implications for this integration (i.e., differing religious and spiritual views of clinicians and clients, clinicians may assume they cannot relate to religious or spiritual clients, or counsellors may unknowingly promote destructive religious or spiritual beliefs, etc.). Conversely, clinicians who are explicitly religious or spiritual clinicians (who engage more frequently in religious and spiritual practices) may be better equipped in some instances to provide religious and spiritual interventions for clients. However this does not excuse other clinicians from making efforts to become competent in addressing their clients' religious and spiritual needs. Curtis and Davis (1999) encourage clinicians to not only explore religious and spiritual issues in counselling but to also find ways to include these dimensions within current counselling theories. Foundational theories do not need to be abandoned but adopted to include these dimensions. This can be accomplished by simply applying religious and spiritual dimensions to one's conceptual framework. Plante (2007) explained it best: "Spirituality and psychotherapy integration is unlikely to be a trendy fad" (p. 900). Counsellors need to explore their own religious and/or spiritual belief system and develop a congruent personal theory of counselling. Some individuals may be reluctant to seek counselling, due to preconceived notions that counselling is incompatible with their faith. Rose, Westefeld, and Ansley (2001) report that 25 potential clients are concerned that clinicians might try to alter a client's religious or spiritual beliefs by either undermining or attempting to convert the client to the clinician's own orientation. However, counsellors can enter into genuine therapeutic relationships (Eliason, Hanley & Leven tis, 2001) lessening negative expectations of current and future clients. The goal of integrating religion and spirituality in counselling is, first and foremost, to facilitate clients' spiritual and psychological growth, not to alter or undermine fundamental beliefs. Religion, Spirituality and Culture Becoming familiar with clients' religious and spiritual beliefs should be considered as important as learning about their cultural norms and values. In many respects integrating religion and spirituality in counselling is conceptually similar to more general multicultural counselling attitudes and skills previously advanced by other multicultural researchers (e.g. , Pope-Davis & Coleman, 1997). Just as specific attitudes and skills are needed for multicultural counselling, so too, similar skills can be applied to religious and spiritual integrated counselling. For example, Walker et al. (2004) report on several of these skills: (a) having an awareness of one's own cultural heritage; (b) respect and comfort with other cultures and values that differ from one's own; and (c) an awareness of one's helping style and how this style could affect clients from other cultural backgrounds (p. 70). Benefits of Clinical Integration It is important for counseling to include spirituality because the evidence we have from research and clinical experience is that the area of spirituality is very important. (Kelly, as cited in Miller, 1999, p.499) 26 Finding articles and other publications on the benefits of integrating religion and spirituality in clinical practice was challenging due to the limited number of publications. This is mostly due to the newness of the idea of incorporation and to the general counsellor reluctance towards integration as previously noted. However, there have been positive strides. Counsellors are becoming more awareness of the importance of exploring clients' religious and spiritual needs. Further research on the profound implications of religion and spirituality on recovery, healing and resilience is becoming more prominent. Despite the potential barriers and negative consequences, there are many positive reasons for integrating religion and spirituality in counselling practice. Curtis and Davis (1999) advise that clinicians can miss valuable opportunities that offer support and foster psychological growth if this essential dimension of human experience is ignored or avoided. Steen et al. (2006) similarly caution that denying a client the right to explore religiosity or spirituality could be misconstrued by the client as a communication of the counsellor derision for the client's beliefs. Religious and spiritual beliefs and practices can facilitate psychological healing and physical health (Hill & Pargament, 2003). Wolf and Stevens (2001) suggest that this extends to areas like depression, anxiety, and adjustment; they also suggest that marital and sexual functioning be included. Helminiak (200 1) argues that counsellors can support aspects of a client's religiosity and spirituality to help foster client growth. These positive aspects may include belief in a loving and caring God, needing to make sense of life events, and commitment to compassion, honesty and goodwill, to name just a few. There is research being conducted regarding the benefits of having a religious or spiritual orientation. Although this is not directly linked to counselling, it does provide another example 27 of how integrating religion and spirituality in counselling can be valuable. In their research on the benefits of having a religious or spiritual orientation, Powell, Shahabi and Thoresen (2003) conclude that a relationship between religion or spirituality and physical health does exist. In another study Hill and Pargament (2003) explain that spiritual strivings are empowering, giving individuals a sense of purpose and meaning even in the heart of distressing life events. They further elaborate that "spiritual strivings offer a unifying philosophy of life, one that leads greater coherence to personality in the face of social and cultural forces that push for fragmentation" (Hill & Pargament, 2003, p. 68). Belonging to a faith or spiritual tradition can provide support to individuals, couples and families. A religious and/or spiritual client, for example, may have greater access to a wide array of religious and spiritual coping methods, benefiting from social support given through his or her religious or spiritual group, in addition to perceived support from God or a higher power. Faithto hope for things which are not seen, but which are true - can be even more important in sustaining resilience than frequent participation in spiritual or religious services or activities. Welsh (1998) reports that medical studies found that faith, prayer and spiritual rituals can fortify health and healing by generating emotions that have positive effects on the immune and cardiovascular system (also see Miller & Thoresen, 2003). In a similar way prayer, according to Helminiak (200 1), sometimes helps individuals let go of anxious thoughts and feelings. Prevalence of Religious and Spiritual Problems Just as religion and spirituality can support and strengthen mental and physical health, so too, religious and spiritual beliefs can be potentially harmful. Faiver et al. (2000) provide ample evidence demonstrating that religious guilt may have negative effects on one's mental health. Religious beliefs may also become destructive. Walsh (1998) provides a clear example of this: 28 "As when a mother's self-destructive drinking is based on her conviction that her child's death is God's punishment for not having baptized the child" (p.74). Similarly, spiritual distress can impede coping and an ability to invest life with meaning. Although individuals do not need to have a "spiritual or religious crises" before these topics can be addressed in counselling, there is evidence suggesting that many individuals do have significant problems related to their religious or spiritual beliefs. In a study of AP A member psychologists, for example, 60% reported that clients often expressed their personal experiences in religious language. Additionally, 1 in 6 of their clients presented issues which directly involved religion or spirituality (Lukoff et al., 1998). It is becoming clearer in the literature that religion and spirituality are viable topics to integrate in counselling. Yet there remains a discrepancy between what is being written and what is being practiced. Carlson et al. (2002) attribute this seeming disparity to two main causes; (1) a lack of education in how to integrate religion/spirituality in therapy; and (2) what they describe as "the newness of [religion and] spirituality as a viable topic for therapy" (p. 167). It appears that there are two core avenues that can be used to present religion and spirituality in counselling. One avenue is to use one's religious or spiritual beliefs to give clients guidance, support and strength to endure or surpass their current problems or struggles. Consider the following clinical case illustration. Clinical case illustration. Jennifer is a single mom working two different jobs to support herself and her three preadolescent children. She has never really been a religious person but has always felt spiritual through her meditation practices. Each morning, Jennifer use to meditate using basic transforming Buddhist meditations. Recently she has become 29 overwhelmed with her job, financial strains and three busy children. Jennifer often feels unhappy, impatient and frustrated. To help herself, Jennifer sought counselling services and has been working through her stress with her counsellor. When her counsellor asked her about self-soothing and containment exercises, Jennifer disclosed that she typically does Buddhist meditation exercises but due to time restraints has discontinued them over the last few months. Through encouragement from her therapist, Jennifer has resumed this spiritual exercise. She continues to struggle with time and finances but Jennifer now finds inner peace and balance because of her meditation practices. With the help of her counsellor, Jennifer has also learned ways of using her meditation exercises throughout the day. Religion and counselling can also be a focus of clinical attention when one's problems are actually being perpetuated or precipitated by one's beliefs. The most common examples of religious problems depicted in the clinical literature include loss or questioning of faith, change in denominational membership or conversion to a new religion, strengthening or stricter adherence to the beliefs and practices of one's own faith, and joining, participating or leaving a religious movement or cult (e.g., Carlson et al., 2002; Lukoff et al., 1998). As an example consider the following clinical case illustration. Clinical case illustration. Aalee moved from Iran to Canada with his family as a young man. His family has always been practicing Muslims. However, since Aalee has been in Canada he has recently been questioning his traditional religious values and has become increasingly interested in Christianity. In fact, since he was sixteen he has been attending regular mass with some of his close friends. He has recently decided to leave his traditional faith to join the Catholic Church. However, when Aalee confronts his parents 30 about this decision he is not only discouraged to join but is told that if he joins this or any Christian religion his family will reject him. Spiritual problems have also been noted in the literature. Lukoff et al. (1998) explain that spiritual problems range from the questioning of spiritual values, loss of spiritual connection, meditation-related problems to mystical experiences, near-death experiences, and leaving a spiritual teacher or path. Hill and Pargament (2003) report that there are three main types of religious and spiritual struggles: (1) interpersonal struggles-these involve religious conflicts between the individual and others; (2) intraindividual struggles-which occur internally, as demonstrated by the strains people experience between the virtues they embrace, their feelings, and their actual behaviours; and (3) struggles with God-questioning God's presence, compassion, authority, or purpose for the individual. As religious and spiritual problems have become more salient and better understood, mental health professionals have taken notice. In fact, the Diagnostic and Statistical Manual Fourth Ed. Text Revision (DSM-4 TR) includes a section specifically dedicated to such problems (APA, 2000). Religious or Spiritual Problems is the new diagnostic category (Code V62.89). This new category states that it "can be used when the focus of clinical attention is a religious or spiritual problem" (APA, 2000, pg. 741). As an example this includes distressing experiences that involve loss or questioning of faith and spiritual values that may not necessarily be related to an organized church or religious institution (see Lukoff, et al., 1998; Wolf & Stevens, 2001). To sum up, religious and spiritual struggles may be particularly difficult because they challenge facets of life that are most revered and imply harsh truths about the human condition, truths that may be definitive, incontrovertible and everlasting. 31 As Sermabeikian (1994) so eloquently taught, religiosity and spirituality are "too important to be misunderstood; avoided; or viewed as regressive, neurotic, or pathological in nature" (p.l81 ). Counsellors will be most effective when they recognize that individuals' religious beliefs and spirituality are fundamentally linked to who they are at the core of life. Even though the integration of religion and spirituality is a relatively new concept, ample evidence points to many positive consequences of responding to these aspects of clients' life experiences. To conclude, clinicians need to be aware that religion and spirituality can be positive aspects ofliving and facing life's challenges for many of their clients. Educational Opportunities As suggested earlier, clinicians are typically not adequately prepared or trained to address religious and spiritual issues with clients, especially compared to training on addressing other diversity issues (i .e. , gender, ethnicity, and sexual orientation/preference). One danger of providing religious and spiritual interventions is the risk of clinicians imposing their own values or using religious and spiritual beliefs and interventions inappropriately (Walker et al., 2004). So how do training programs prepare clinicians to work competently with religious and spiritual clients? Further, how can practicing clinicians become competent in this area? There has been a significant increase in research articles being published describing advanced courses in spirituality (e.g. , Cashwell & Young, 2004; Leseho, 2007; Myers & Williard, 2003; O'Connor, 2004; Pate & Hall, 2005 ; Souza, 2002). Indeed, there are more opportunities today for students and clinicians to become competent in religious and spiritual matters related to counselling than ever before. Pate and Hall (2005) assert that education opportunities, dedicated to fostering the integration of religion and spirituality within clinical 32 practice, reinforce how vital it is for counsellors to accept and understand the significance of religiosity and spirituality of those they help. Yarhouse and Fisher (2002) report there are a variety of models used for integration today (i.e., Integration-Incorporation Model, Certificate-Minor Model and Religious Distinctive Model) . Through their research article, these authors provide a number of advantageous recommendations. Furthermore, by adopting ideas from established programs, educators, counsellors-in-training and clinicians can increase their competency for working within clients ' religious and spiritual orientations. Table 2.3 is a summary of the points Yarhouse and Fisher recommend. Table 2.3 Education and Training Opportunities • Complete continuing education in working with a specific religious or spiritual tradition • Complete continuing education in the assessment of mental health concerns and their impact on religious and spiritual functioning • Attend a conference or seminar sponsored by religiously affiliated clinicians • Take an elective through a training program that follows a religious or spiritually distinctive model • Enroll in an elective through a program with a certificate or minor in religion or spirituality • Cultivate professional relationships with other clinicians who are members of a religious or spiritual tradition with which they are unfamiliar • Complete readings on religion and spirituality • Obtain consultation from a clinician whose expertise is in religious and spiritual issues in clinical practice (Yarhouse & Fisher, 2002) Ethical Implications The inclusion of religion and spirituality in counselling has historically been seen as an ethical mire for potential problems and dilemmas. Nevertheless, current literature provides contrary evidence. Students in many counselling programs, for instance, are trained to be 33 sensitive to cultural diversity, including spiritual and religious issues. There is growing body of literature on developing counselling and spirituality courses to better help counsellors integrate spirituality into their professional practice (e.g., Cashwell & Young, 2004; Curtis & Glass, 2002; Leseho, 2007; Myers & Williard, 2003; 0' Connor, 2004; Pate & Hall, 2005; Richard & Bergin, 2005; Souza, 2002). Despite the growing evidence for the need to include spirituality in counselling, there is still little known about the positive and negative outcomes that may result from spiritual interventions (Richards & Potts, 1995). Moreover, even though growing evidence supports including spirituality in counselling, critics maintain that its integration in counselling is ethically and professionally dangerous (Plante, 2007). As such, including spirituality in clinical practice requires sensitivity to several ethical considerations. I wish to highlight only a few of these considerations here: (1) client welfare; (2) concern for unhealthy spiritual beliefs; (3) professional competency; and (4) dual relationships in relation to religion and spirituality. One's relationship to religiosity and spirituality is highly personal and intimate. Careful consideration must be used when deciding to either include or exclude religion and spirituality during psychotherapy. According to the Canadian Counselling and Psychotherapy Association (CCPA, 2007) Code of Ethics, counsellors need to be sensitive to diversity by striving to understand and respect those they counsel. This includes being sensitive to cultural, spiritual, and religious values and beliefs. Similarly, the Canadian Psychological Association (CPA, 2000) Code of Ethics clearly explains that counsellors are responsible to protect and promote the welfare of their clients (Ethical mandates in other countries, i.e., American Psychological Association, provide similar guidelines). 34 Equally important, many clients believe religion and spirituality are an important component of human development, closely connected to personal growth (Plante, 2007). As such, addressing spirituality in therapy can affect the course of treatment and alleviate suffering, ultimately promoting client welfare. In the same way, intentionally maintaining a secular approach to counselling may provide an insufficient, if not, "alien," framework (Steen et al., 2006). Hence, client welfare may be positively affected by religious and spiritual exploration if counsellors are willing to create such an environment. To prevent unethical practices related to client welfare and religiosity and spirituality, Corey et al. (2007) explain that the role of the counsellor is to recognize and integrate the morals, philosophies, and practices involved in clients ' religiosity and spirituality to "enhance coping"(p.89). This includes being aware of the subtle ways clinicians may be inclined to "push" certain values on their clients. As professionals, counsellors are not required to agree with all faith beliefs and behaviours of clients. Even if counsellors consider some religious or spiritual points of view distasteful and destructive, they are asked to be respectful of the religious and spiritual beliefs, traditions, and behaviors of others (Plante, 2007). Burton and Bosek (2000) provide several guidelines for working with religious and spiritual clients and their families (see Table 4). These guidelines offer a starting point for counsellors to meet ethical mandates put forth by ethical regulatory organizations. 35 Table 2.4. Guidelines for Working with Religious/Spiritual Clients 1. Seek to work within clients' expressed value system 2. Evaluate whether the religious or spiritual claim is consistent with the teaching and practice ofthat faith community 3. Seek to avoid taking a "we verses them" stance 4. Ask ourselves if we would have a similar response to the decision ifthe rationale was not religious or spiritual 5. Does the action create potential or real harm for anyone other than the individual 6. Listen until you can communicate the perspective (and values) of other perspectives 7. Seek a solution that provides mutual good and avoids individual harm (Burton & Bosek, 2000, p. 103-104) Unfortunately, clear ethical guidelines regarding the integration of spirituality and counselling still do not exist. As an illustration, Richards and Potts (1995) state that "many questions about how we can implement a spiritual strategy into mainstream psychotherapy, practice effectively and ethically, remains unanswered" (p.164). Nevertheless, it is clear that religious and spiritual integration is relevant and important in counselling. Closely monitoring ethical issues that emerge or are likely to emerge during counselling is vital (Plante, 2007). Even though some counsellors feel inept to encourage open discussion of religion and spirituality, Steen et al. (2006) offer hope. They suggest that mere acceptance of spiritual exploration and a willingness to view religious and spiritual values as potential elements of counselling may promote the well-being of clients. Of most importance, clinicians ought to be prepared to deal with religious and spiritual issues that lie at the very essence of many clients ' beings. 36 Conclusion Religiosity and spirituality are developmental processes that are natural and life enhancing, giving purpose and meaning to life. It appears that the tradition of separating religion and spirituality from counselling has resulted in many clients disclosing only portions of their experience that fit customary expectations, removing important religious and spiritual aspect of their lives. Because this unfortunately happens, Walsh (1998) advocates for counsellors to not simply wait for their clients to bring up spiritual matters, presuming them to be irrelevant if not articulated, but to show comfort and courteous interest in exploring the religious and spiritual domain lived by clients. As religion and spirituality are integral to clients' lives, many people have questions and struggle with their faith tradition or orientation. This struggle often brings individuals to counselling. Therefore, integrating religion and spirituality in counselling should be considered, just as other diversity issue ought to be. The literature suggests ample evidence in favor of integrating religion and spirituality. I am confident that we as counsellors will be able to explore religious and spiritual experiences with our clients, especially those that have been constructive; such as moments of internal harmony, which can be drawn upon and extended as foundations of resilience (Welsh, 1998). We can facilitate change through the exploration of clients' religious and spiritual protective factors and by being supportive as clients dismantle unhealthy religious and spiritual beliefs and assumptions, all the while endeavoring to do so in an ethical manner. 37 Section 3: Religion, Spirituality and Counselling Practice: Guide to Clinician Responsibilities Novice counselors idealistically, but naively, often think they can do everything for every client they see. With clinical experience comes the realization of clinical/imitations. This is not to say that we must not strive to do our best; of course, we should! An important component of the therapeutic training process, however, involves that of realizing limitations and the consequent setting of therapeutic boundaries. Seeking to constantly upgrade our theoretical knowledge, knowing how and with whom to consult, and knowing when to refer are basic boundary-setting techniques of counseling in general and useful when dealing with clients' spiritual domains in particular. Moreover, implicit in this aspect of competence is the counselor's willingness to selfexamine beliefs, needs, and what Jung (1902/1980) called one 's "shadow side. " (Faiver & Ingersoll, 2005, p.169) Client's religious and spiritual beliefs are particularly sensitive and complex; addressing such issues can be controversial as they relate to counselling. Nevertheless, the counselling field is coming to recognize the importance of addressing religious and spiritual concerns (Corey et al., 2007). Clinicians ask about nearly every facet of clients' lives, yet many clinicians never think to investigate the influence and meaning of religion and spirituality for clients. As little to no formal training in graduate and postgraduate programs on integrating religion and spirituality is available, clinicians are on their own in accessing acceptable training and supervision (Plante, 2007). My intentions here are to give clinicians the knowledge and tools to competently and confidently explore their clients' religiosity and spirituality. The first portion of this section of the guide describes professional competencies as they relate to integrating religion and spirituality in counselling practice. This includes: competencies, countertransference, and clinician responsibilities. The final portion of section 3 of the guide 38 focuses specifically on client welfare which includes: validating positive aspects of religiosity and spirituality, developmental readiness and destructive beliefs and practices. Professional Competencies and Responsibilities Counselling can help individuals gain insights into the ways their core beliefs and values are reflected in their behaviour. They may discover that they need to examine or even reexamine these values. As Corey et al. (2007) maintain, religion and spirituality are major sustaining powers that keep many clients going when all else fails. For this reason, counsellors should strive to be professionally competent in not only secular psychological practices which include multicultural competencies, but also in spiritual and religious counselling practices (Lonborg & Bowen, 2004; Steen et al., 2006; Walker, Gorsuch, & Tan, 2004). Nevertheless, the implementation of spiritual interventions in counselling potentially raises difficult questions. Richard and Potts (1995), for example, question to what extent counsellors are crossing professional role boundaries or competencies when implementing religious and spiritual interventions. More importantly, code of ethics directives endeavor to ensure counsellor competencies are adhered to. CCPA (2007), for example, maintains that "counsellors limit their counselling services and practices to those which are within their professional competence by virtue of their education and professional experience, and consistent with any requirements for provincial and national credentials" (emphasis added, p. 5). This point is reflected in Plante's (2007) argument that being a member of a faith tradition does not make one an expert. Counsellors should be cautious in using their own religious and spiritual beliefs, experiences and knowledge in clinical practice. This is based on the complexity found in the extreme variation of clients' faith 39 traditions. Walker et al. (2004) suggest that the potential danger rests in the risk of counsellors imposing their own values or inappropriately applying religious or spiritual interventions. The CCP A (2007) code of ethics further elaborates on professional competence by suggesting counsellors refer clients to other professionals, "when the counselling needs of clients exceeds their level of competence" (p. 6). Fortunately, competency levels regarding spirituality and religion can be reached by most counsellors. As an illustration, Richard and Bergin (2005) offer several recommendations about training to better ensure competence in religion and spirituality in counselling integration. They suggest: (a) that counsellors read books and other publications available on integrating religion and spirituality within counselling; (b) attend applicable workshops and seminars; (c) seek supervision and consultation from competent colleagues; and (d) learn more about the spiritual and religious traditions typically encountered with clients. As previously noted, counsellors most often neglect religious and spiritual dimensions from a lack of awareness rather than malfeasance. Clinical case illustration. Gavin is a LDS (Mormon) counsellor is well known in his religious community, as he was a former Bishop and has held many other responsibilities within the LDS Church. His client, Samantha, is experiencing a great deal of guilt and shame that she attributes to her LDS background. She has generalized anxiety disorder and is worried about how her thoughts, behaviors, and impulses might be immoral. She knows that Gavin is LDS and asks if some of her thoughts and feelings, which she is embarrassed about and too uncomfortable discussing with her Bishop, might be sins. She further asks questions about many of the church's doctrines. For instance, Samantha enquires about life after death and whether her thoughts and feelings are damning her. While Gavin has thoughts on these matters as a Mormon, he informs her 40 that these types of questions might best be addressed with her Bishop and other church leaders. Gavin does, however, explain to Samantha that counselling can help with the feelings she is experiencing due to her religious and spiritual queries and provides her with coping strategies associated with her guilt and anxiety. In this example Gavin simply articulated his area of competence and provided Samantha with appropriate referrals to help address her religious questions. Gavin further clearly explained where his competency boundaries started and ended; for instance, he explained that he could help Samantha with the feelings associated with her religious beliefs but let her know that it would be beneficial for her to speak to her Bishop or other church leaders. Due to their similar religious beliefs, it could have been very easy for Gavin to express his personal beliefs but this would have been outside his professional boundary. In their insightful review of ethical values in counsellors, Jennings and colleagues (2005) reveal that exceptional clinicians highly value being very skilled in their clinical work. They report that these clinicians are highly motivated to move beyond the minimum competency levels required toward expertise in their field. This includes maintaining and building their skill set-integrating spiritual and religious competency training into this skill set may easily be included. Drawing from Richards and Potts (1995) conclusions, despite the ethical dangers associated with implementing a spiritual orientation in counselling, maintaining a position of religious and spiritual aloofness is dangerous and unjustified. This includes learning about the individual culture of clients and the impact of one's own cultural beliefs and possible biases toward others (Miranti & Burke, 1992). Here culture can clearly be extended to religious and spiritual beliefs, practices and experiences as most religions are enmeshed within culture. 41 The Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC; 2009) offers a practical and simple overview of competencies for addressing spiritual and religious issues in counselling (see Table 3.1 ). These principles are intended to help clinicians assess ways of self-improvement and evaluation. Belonging to a Faith Tradition At times it may become easy for clinicians, who have similar religious and/or spiritual values as their clients, to assume they know what their clients ought to be doing or not doing in regards to spiritual or religious challenges. This also includes counsellors assuming they know how their clients are feeling regarding religious or spiritual beliefs. Plante (2007) maintains that counsellors should be careful of using their religious or spiritual knowledge in clinical practice. It is important that counsellors not presume to be experts in their faith tradition or other religious/ spiritual traditions. This includes clinicians working to not appropriate the role of clerics in their professional work unless their professional role includes these areas of expertise. Even in such a rare case, counsellors must be cautious. Members of faith traditions do vary greatly in their knowledge and comfort level; this includes one's interpretations and application of religious traditions and teachings. In talking about value differences between clinicians and clients, Slife and Richards (200 1) explain: "We believe that the open, explicit and respectful acknowledgement of these differences would do more to build trust and credibility than any attempt at impartiality" (p. 202). The following clinical case illustration exemplifies how one counsellor's faith tradition might interfere with her clinical work. Diagnosis and treatment Assessment Communication Human and spiritual development Counsellor selfawareness Culture and Worldview Competency Principle 2. The clinician uses religious and spiritual concepts that are consistent with the client's religious and spiritual perspectives and that are acceptable to the client. 3. The clinician can recognize religious and spiritual themes in client communication and is able to address these with the client when they are therapeutically relevant. 1. When making a diagnosis, the clinician recognizes that the client's religious and spiritual perspectives can: a) enhance well-being; b) contribute to client problems; and/or c) exacerbate symptoms. 2. The clinician sets goals with clients that are consistent with the clients' religious and spiritual perspectives. 3. The clinician is able to: a) modify therapeutic techniques to include a client's spiritual and/or religious perspectives, and b) utilize religious and spiritual practices as techniques when appropriate and acceptable to a client's viewpoint. (ASERVIC, 2009, p. 1-3) 4. The clinician can therapeutically apply theory and current research supporting the inclusion of a client's religious and spiritual perspectives and practices. 1. During the intake and assessment processes, the clinician strives to understand a client's religious and spiritual perspective by gathering information from the client and/or other sources. 1. The clinician responds to client communications about religion and spirituality with acceptance and sensitivity. 2. The clinician continuously evaluates the influence of his or her own religious and spiritual beliefs and values on the client and the counseling process. 3. The clinician can identify the limits of his or her understanding of client's religious and spiritual perspective and is acquainted with religious and spiritual resources, including leaders, who can be avenues for consultation and to whom the counselor can refer. 1. The clinician can describe and apply various models of religion and spiritual development and their relationship to human development. 1. The clinician actively explores his or her own attitudes, beliefs, and values about religion and spirituality. 2. The clinician recognizes that the client's beliefs (or absence ofbeliefs) about religion and spirituality are central to his or her worldview and can influence psychosocial functioning. Competency Guidelines 1. The clinician can describe the similarities and differences between spirituality and religion, including the basic beliefs of various spiritual systems, major world religions, agnosticism, and atheism. Table3.1 Religious and Spiritual Competencies 42 43 Clinical case illustration. Abigail, an Anglican, sought out counselling services recently because she is at a loss as to how deal with her husband, Scott's, resistance to attend church services with her. Abigail states that she has always enjoyed church, particularly the support and encouragement she gets from other members. Excitedly, Abigail reports that she and Scott will be having a baby in six months. As an Anglican, Abigail feels her children need to be baptized and for the family to attend church together. Recently, Abigail has experienced significant fear and guilt that if she pushes Scott too much to attend church services she may lose him. Abigail's counsellor Dagan, who is Roman Catholic, sympathizes in many ways with what Abigail is experiencing. She too believes all children should be baptized, attends Mass regularly and has a reluctant husband. In counselling, Dagan recommended that Abigail be assertive in her beliefs and convictions. She further instructed Abigail on gender issues and encouraged Abigail to hold fast to her beliefs, regardless of her husband's contrary beliefs. Unfortunately, this restrictive approach by Dagan left Abigail feeling just as uncertain and conflicted regarding her situation. In this scenario it appears that Dagan overstepped her professional role boundaries and that her personal faith traditions impacted her treatment plan with Abigail. Consider the following questions : What personal issues of Dagan's were possibly infringing on her effectiveness as a counsellor? In what ways might Dagan's religious experience be influencing the way she counsels Abigail? What recommendations would you suggest for Dagan in moving forward with Abigail? And considering Abigail's position, how might you feel if you had Dagan as your counsellor? There are possibly other concerns that may need addressed. For instance, it 44 appears Dagan may be experiencing countertransference (see section on countertransference, p. 46) and may benefit from competency training specifically addressing religiosity and spirituality. Many counsellors who actively pursue religious and spiritual integration within clinical work themselves belong to and are active in a religious or spiritual tradition. As such, they may feel quite content and even knowledgeable about their orientation but remain unfamiliar of other faith or spiritual traditions. At times this may be problematic. For example, if a counsellor who is active in one faith or spiritual tradition feels uniformed about issues related to other faith or spiritual traditions he or she ought to keep personal biases in check. In a similar way, believing your religious or spiritual tradition is more accurate may be particularly problematic. Such a belief may not always be negative, but one must be cognizant that such a belief system may bias clinicians toward specific clients. As these issues are particularly important to address, Plante (2007) recommends clinicians receive ongoing consultation and supervision to help them better understand and manage these potential conflicts. It is essential for counsellors to remember that they are practicing as professionals who, as Faiver and Ingersoll (2005) emphasize, identify religion and spirituality "as an important component of the human condition and, thus, the therapeutic relationship" (p.179). As counsellors strive to integrate religion and spirituality within therapy, remaining competent includes using one's own religious and spiritual knowledge appropriately. Counsellors do not need to assume the role of clerics or spiritual teachers to understand the central beliefs and values of their clients' decision making (Watts, 2001). One of the best ways clinicians can practice well within their competency is through self-awareness. 45 Counsellor Self-Awareness Counsellor self-awareness is the exploration of how personal feelings, attitudes, and biases affect work with clients. Aptly relating with clients and their value systems necessitates a great deal of self-awareness. In much the same way that counsellors are encouraged to explore their own psychological issues, they are also encouraged to be self-aware of their religious and spiritual issues. This is a main requirement for clinicians to remain ethically and therapeutically sound in their work. Hagedorn (2005) suggests that counsellors can only assist clients through the self-exploration process of religion and spirituality if they themselves as clinicians are committed to the exploration of their own religious and spiritual beliefs, practices and experiences. He concludes that "increased self-awareness leads to improved clinical practice" (p. 64). It may be necessary for counsellors to resolve any historical religious or spiritual issues of their own that might impede the therapeutic relationship (Eriksen, Marston, & Korte, 2002). In a similar fashion Lonborg and Bowen (2004) suggest that counsellors not only strive to be cognizant of their embedded religious and spiritual values, but find ways to manage such values when counselling diverse clients. This includes being proactive in reconciling possible conflicts between their professional role and personal religious and spiritual values. In the fifth section of this guide under the heading Clinician Religious and Spiritual Beliefs, specific ideas and assessment procedures will be provided to help counsellors increase their self-awareness through a variety of activities and self-exploration strategies. Personal Needs and Values Personal needs and values need to be considered, especially as they relate to integrating religion and spirituality. Clinicians cannot avoid the values they hold, and this may lead to them attempting to use those beliefs to impact their clients. Slife and Richards (200 1) acknowledge 46 this dilemma and argue that the "only ethical course of action is to make themselves [as counsellors] aware of these values and use this knowledge to inform their clients" (p. 202). These authors further provide several ways counsellors can remain ethical and reduce imposing their own values. Table 3.2 is a summation of these suggestions. Table 3.2 Avoiding Values Imposition • Counsellors must acknowledge that not all clients will or should accept their values • Counsellors should do their best (and be trained to do their best) to explicate their values, including their theological values, during therapy • Counsellors need to emphasize that their clients have the right to disagree with them • Counsellors should see such disagreement as a potentially productive part of the therapy interaction • This approach acknowledges the inevitability of counsellor influence on clients but decreases the likelihood that inappropriate "value imposition" will occur (Slife & Richards, 2001, p.202-203) Countertransference Why beholdest thou the mote that is in thy brother's eye, but considerest not the beam that is in thine own eye? Or how wilt thou say to thy brother, Let me pull out the mote out of thine eye; and, behold, a beam is in thine own eye? Thou hypocrite, first cast out the beam out of thine own eye; and then shalt thou see clearly to cast out the mote out of thy brother's eye. (Mathew 7:3-5, King James Version) There is always a risk that counsellors might unintentionally or purposefully impose their own values on their clients. This includes indoctrinating clients with a particular set of religious or spiritual values. The therapeutic relationship has always been emphasized as it is the basis for therapeutic change. Corey (2005) warns counsellors to guard against making decisions for their ~ 0 - - 47 clients. Case (1997) also suggests that clinicians attend to their attitude and feelings toward their clients, with this awareness one of the most important factors in facilitating therapeutic change. Research into the impact of clinicians' values on their clients has increased due to the belief that counsellors do not hold an unbiased presence in the counselling process (e.g., Curtis & Davis, 1999; Frazier & Hansen, 2009; Griffith & Griggs, 2001 ). Case (1997) further elaborates that this interactive approach is implicit in the expectation that clinicians are adequately cognizant of their influence "to the relational atmosphere, as well as how their own psychological issues might color their interpretation of the client's transference" (p. 97). When clinicians impose their values and beliefs onto their client's, countertransference often results. Countertransference, according to Hofsess and Tracey (20 10) "refers to the therapist's feelings, cognitions, and behaviors that occur in response to dynamics occurring in the counseling relationship that stem from either the therapist's unresolved issues or from the maladaptive behaviors elicited by the client" (p.52). Countertransference is neither limited to any theoretical orientation nor is any therapist exempt from experiencing it at some point in therapy. Gelso and Hayes (2007) suggest there are five fundamental features for understanding countertransference. These include: (a) its origins; (b) triggers; (c) manifestations; (d) effects; and (e) management. Clinical case illustration. Seraph was raised in an Anglican home but has sense denounced religion claiming all religions are destructive; however, he considers himself a spiritual person. Recently he has begun noticing that he treats his highly religious clients slightly different than all other clients. Reflecting on this, Seraph has noticed that many of these clients do not progress in counselling as well as most other clients; he attributes 48 this in part to the poor therapeutic relationship he establishes with highly religious clients. In light of this new introspection, Seraph is now consulting with colleagues and his supervisor regarding religious countertransference issues. He is also developing appropriate referral networks for those clients that could best be served by clinicians more competent in working with religious clients. Just as Seraph found, these five countertransference features are important to consider as counsellors assess to what degree countertransference might be infringing on their clinical practice. Again it appears religion and spirituality in particular can often lead to countertransference. A clinician raised in a agnostic or atheist family in which religion was shunned, for example, may feel he or she is betraying their family if they address their clients' religious problems. Clinicians face a number of potential sources of countertransference that could certainly be overlooked or ignored. Clients may come to counselling, for example, having issues that are comparable to his or her counsellor's issues. Frame (2005) emphasizes that when both clinician and client issues "collide in the therapeutic process, counselors are more vulnerable to being pulled into their clients' system" (p. 21 ). This is particularly true of counsellors who have clients who also profess similar beliefs. Weld and Eriksen (2007) explain that as counsellors strive to find balance between psychological, religious and spiritual matters, countertransference may produce boundary violations. In other words, playing two roles (e.g. , counsellor and pastor) simultaneously may not only confuse clients but can lead to unclear boundaries between the two roles. I have already addressed the need for clinicians to guard against pushing their own religious and spiritual agendas. By the same token, clinicians may foist their nonreligious or 49 antireligious beliefs. Countertransference may be exceptionally hard for clinicians to overcome who have had negative experiences with religion or spirituality. For example, as a child Mary was repeatedly indoctrinated by her parent's anti-religious views. Now as an adult, she is an atheist but can only attribute her beliefs to never feeling a connection to any Deity or religious beliefs. Weld and Eriksen (2007) suggest individuals such as my example ofMary may not see the need for religious or spiritual integration. Neither are they then likely to seek education opportunities regarding religious and spiritual beliefs, practices and experiences nor are they likely to invest emotional energy into such a therapeutic relationship. A worse-case scenario would be counsellors who try to convince clients to renounce their faith or church because of the opinion that these beliefs and practices might in some way be perpetuating mental health issues. As a counsellor-in-training I had an experience similar to this. A colleague was practicing basic counselling skills on me and the discussion turned to morals and religion. Acting in the role of the therapist, my colleague, who claims to be atheist, could not understand my religious morals and proceeded in trying to persuade me that my moral values were too rigid and that my religion was asking too much of me or any member. This clinician was clearly imposing his or her own values on me; presenting assumptions that were unprofessional and made me feel uncomfortable. Other less experienced clinicians like my colleague, may unknowingly or with good intentions impose their own views regarding religion and spirituality. I am not suggesting my colleague was experiencing countertransference; however, his or her previous experiences with religion may have contributed to the views presented. Countertransference is particularly problematic when clients' beliefs are neither unhealthy nor problematic. The following clinical case illustration provides another example of countertransference. 50 Clinical case illustration. Shoaib is a marriage and family therapist who claims to be an atheist. Shoaib's beliefs are a result of the negative childhood experiences he had growing up in a strict Muslim home. He is currently working with Owen who initially came for counselling because of marital problems. Owen's wife has been unwilling to participate in counselling, crediting all their marital problems to Owen. Shoaib explores with Owen the possibility of him leaving his wife but Owen simply states this is not an option. He informs Shoaib that he has deep religious and spiritual beliefs that this marriage is his destiny and that if he were to contradict his destiny he would undergo suffering in some other form. Surprised by such thinking Shoaib asks Owen if he realizes his beliefs may be negatively affecting him as well as his children. In this scenario Shoaib clearly had a hard time accepting Owen's convictions. Shoaib was not only thinking that Owen's beliefs were unhealthy for him, but he also attributed those beliefs to be negatively affecting his children. Do you think Shoaib was taking care of his needs or of Owen's needs? Do you feel Shoaib would need to agree with Owen's beliefs in order to work with him? And more importantly, how would you work with such a client? In his article on countertransference among religious therapists, Case ( 1997) emphasized that there are a variety of sources of countertransference that religious and spiritual therapists encounter. Unfortunately space does not permit an in-depth analysis of these; however, I have summarized the sources in the following table in hopes they will stimulate discussion and greater awareness among clinicians (see Table 3.3). Countertransference in clinical practice may not always be avoided but counsellors need to be aware of their personal triggers. Ultimately the therapeutic relationship can be affected Counsellors unwittingly view all client problems as needing spiritual interventions even when valid psychological interventions are appropriate. This view may easily be perpetuated as clients whom are misinformed of their counsellor's role encourage such practice. The counsellor may experience negative feelings for religion and religious groups because of "unresolved rebelliousness" (p.4). All spiritual interventions are avoided; the counsellor may even convey defiance toward client's religious beliefs, practices and experiences. The Spiritualizer The Reactionary My way is Yahweh (Case ,2007) This type of countertransference is illustrated by counsellors who pose as the expert in religious and spiritual matters. Either consciously or unconsciously they do not recognize there are many different valid views and understandings about specific religious and spiritual issues. Clients may view such viewpoints as authoritative because of the powerful position counsellors hold. This counsellor expresses excessive curiosity about his or her client's "secrets" to gratify own needs or desires. For example, they may ask about clients ' sexual experiences. This is usually due to counsellors' restrictive beliefs (e.g., religious moral codes regarding sexuality). Counsellors use the therapeutic relationship either consciously or unconsciously to proselytize clients. The Missionary The Window Shopper Counsellors share religious commonalities with their clients and on a continuum engender excessive agreement or lose objectivity because of their similarities; this may also include expectations of one's religious community. Brief description The Sibling Complex Potential Source Table 3.3 Potential Sources of Countertransference 51 52 when counsellors place too much or too little attention on religious and spiritual issues. Countertransference can have negative results when, for example, counsellors avoid addressing religious and spiritual concerns, react negatively toward such discussions, and react positively to the possibility of dissuading clients from particular religious or spiritual beliefs or practices. It is not enough to just talk about countertransference and its potential, but clinicians need to have direction on how to deal with it as professionals. Miller (2005) maintains that counsellors need to examine their own issues related to religion and spirituality and then to process possible countertransference issues with competent colleagues or supervisors. He suggests the following questions be explored: (1) Given my countertransference issues can I competently work with this client? (2) Should I continue therapy or should I refer the client to a more competent professional? (3) Ifl do continue working with this client what boundaries can I effectively establish and how will I address these concerns in session? And (4) if a referral is deemed necessary how will I discuss this issue with my client? Counsellors can minimize countertransference issues though both personal and professional means. For example, Miller (2005) reports that on a personal level counsellors can examine both their negative and positive views about religion and spirituality, looking for opportunities to investigate different religious and spiritual experiences than their own, and perhaps more importantly, be actively engaged in developing their own spirituality. Counsellors can strive for competence through following current literature, becoming competent in relevant intake and assessment procedures, integrate therapeutic techniques that involve a religious and spiritual perspective when appropriate, and obtain competent consultation and supervision. Aten and Hernandez (2004) suggest that supervisors can help clinicians shift their perspective on integrating spirituality/religiosity through helping them assess their actions and 53 convictions and look for discrepancies that may be hindering the therapeutic process. These authors suggest the following question be addressed: Are religious and spiritual issues and themes being ignored in session because the client is uncomfortable or is it because the counsellor is uncomfortable with these topics? One of the best ways counsellors can address this question is through self-assessment. Self-assessment, which has been briefly discussed previously (and will be discussed in greater depth in section 5), is another important way for counsellors to assess when they find themselves navigating this realm. This self-examination process can provide ample opportunities for clinicians to consider their own religious and spiritual attitudes. Hopefully such scrutiny will, as Weld and Eriksen (2007) maintain, help clinicians assess their perception of integrated religiosity and spirituality, evaluating if their viewpoint is "normal or neurotic, mature or immature" (p. 134). Countertransference issues can happen in everyday secular counselling; however, it seems countertransference may happen more often when religion and spirituality issues are encountered. This is perhaps true in part because every human being is influenced by religion and spirituality, positively or negatively. Counsellors typically labor very hard to resolve countertransference issues they experience with clients; however, "clients need protection from the potentially harmful effects of the therapist's inability to work with [religious and] spiritual issues" (Weld & Eriksen, 2007, p.l35). When this happens, as Genia (2000) advocates, counsellors need to make appropriate referrals to either competent counsellors or to appropriate religious and spiritual teachers. 54 Blurred Boundaries and Dual Relationships Many professionals who integrate religion and spirituality in counselling are active in some faith tradition or ascribe to one or more spiritual traditions. Similarly, many religious and spiritual people wish to work with counsellors who share similar faith and/or spiritual traditions and interests. Therefore, dual relationships may become quite common in this setting. For example, counsellors who are active members of a religious or spiritual tradition may receive continuing referrals from their clergy or church group. At what point is the individual acting as a religious leader verses a professional counsellor? It is easy to see how easy it might be to blur boundaries and even cross into unhealthy dual relationships. Plante (2007) suggests this creates boundary crossings and perhaps boundary violations as the counsellor now treats and/or evaluates members of his or her own religious or spiritual community. Further considerations must be given to those who are not only counsellors but also members of a clergy. Accordingly, beside their role as minister, they provide professional counselling services. As such, this provides easy opportunities to blur professional boundaries, despite the usefulness of having a minister who has extensive psychological training (see Plante, 2007). Moreover, this could develop potentially challenging and perplexing dual relationships. Slife and Richards (200 1) provide several valuable suggestions to handling boundary issues. They suggest: "(a) openly acknowledge to clients that their approach to psychotherapy contains theological assumptions and implications; (b) emphasize to clients that they (the therapist) are not religious authorities and have no right to authoritatively teach theological doctrine; (c) acknowledge the rights (and duty) of clients to disagree with the counsellor's theological views; and (d) encourage clients to seek counsel from their religious leaders if they have theological questions or concerns" (pg. 201 ). . - - - - - - - - - - - - - - - - - - - - - - - -- - - - 55 To ensure proper ethical behaviour there are several guidelines that can be implemented to help prevent dual relationships or to help maintain clear boundaries. Not treating one's own parishioners, for example; or keeping clear boundaries and knowing when to consult or refer clients is critically important Similarly, Plante (2007) offers several suggestions that should be considered when entering into a dual relationship. These include "taking into consideration the nature of the professional work, the size of the religious congregation, the type of possible dual relationships that might emerge, and the need for clarity of roles and responsibilities" (Plante, 2007, p. 897). Clearly dual relationships cannot always be avoided; nevertheless, special care needs to be given before and during the process when counsellors think they may be entering a dual relationship involving religion and/or spirituality. Client Welfare At the center of the counselling profession is concern for our clients. This concern goes beyond meeting individuals where they are at, but to also ensure client's beliefs, values, and traditions do not cause harm to self or others. Our concern as counsellors for the welfare of others must be paramount (Plante, 2007). Briggs and Rayle (2005) emphasize that while religious and spiritual beliefs and practices can promote overall mental health and well-being, these beliefs can also be carried out in ways that cause psychological suffering. When highly religious or spiritual individuals, for example, use their beliefs and/or practices to refute or suppress problematic and powerful feelings such as grief and anger or to attribute all control and accountability for life happenings on outer influences, difficulties such as depression, anxiety, and poor personal functioning can result 56 As clients bring therapeutic problems arising from religion and/or spirituality into counselling, a variety of problems may be involved. For example, Frame (2005) argues that problems between religion/spirituality and personal realms (i.e., family, work, social, & community life) potentially can cause concern for clients. Consider the following examples: • Sarah is a practicing Jehovah Witness and is very active in her religious community. However, over the past few years she has begun to develop a sense of resentment and guilt toward her co-workers. She explains that the office staff where she works traditionally acknowledges team members on their birthdays. This includes staff members taking turns bringing a cake for the occasion and interoffice birthday celebrations. Sarah continually feels guilty for not participating because of her religious convictions, even though her coworkers explain to her that they understand. But at the same time she has become increasingly resentful because she feels pressured to contribute despite her beliefs. • Lincoln, who was raised a Roman Catholic but does not actively participate in church services, is experiencing a great deal of anxiety because he and his fiancee, who are planning to be married cannot agree on an which type for ceremony to have. His fiancee, Mary, is First Nations and would like a traditional wedding. However, he feels pressured by his parents to be married by the Catholic minister. Both Lincoln and Mary are at odds as they are being pressured from their respective families, communities and cultural heritages. Validating Aspects of Religiosity and Spirituality Counsellors can judiciously support religious and spiritual facets of their clients. This can be accomplished by validating aspects of clients' worldviews. Religious and spiritual beliefs and 57 practices can facilitate psychological healing and personal integration. Helminiak (200 1) provides several examples: "belief in a loving and caring God; the need to make some sense of life's happenings; commitment to honesty; compassion, and goodwill; requirements about repentance and forgiveness; membership in a supportive community; participation in moving and reassuring rituals; and practice of private devotions and meditative exercise" (p. 173-174) all demonstrate how client's religious and spiritual practices can facilitate strength and growth. The following clinical case illustration, which provides an excellent example of validating healthy religious beliefs, is replicated from Corey et al. (2007). Clinical case illustration. Rory, who has been in counselling for some time with Teresa, sees himself as a failure and cannot move past his guilt. He insists that he cannot forgive himself for his past. He is in great turmoil and berates himself for his aberrant ways. Teresa knows that Rory is a profoundly religious man and asks during one session: "How would you view and react to a person with a similar struggle as yours? What kind of God do you believe in? Is your God a punitive or loving God? What does your religion teach you about the forgiveness of sin?" Teresa is attempting to utilize Rory's convictions to reframe his thinking. Once he begins to look at his behaviour through the eyes of his religious beliefs, his attitudes toward his own behaviour change dramatically. Because Rory believes in a living God, he finally learns to be more forgiving of himself. (Corey et al. , 2007, p. 95) In what ways would you act similar or different than Teresa? Would you feel comfortable in using Rory's own religious and spiritual beliefs as an intervention? Teresa was perceptive in noticing the discrepancy between Rory's internalized beliefs about himself and those involving his religious convictions. 58 Destructive Beliefs and Practices A man in the East was found sitting on his roof because a great tidal wave was sweeping through the village. The water was well up to the roof when along came a rescue team in a rowing boat. They shouted, 'Well, come on. Get into the boat. 'But he said, 'No, no. God will save me. ' This happened twice, and finally along came a helicopter, but still he said the same. Eventually, the water covered his head and he drowned. When he got to heaven, he complained with these words, 'God, why didn't you try to save me?' And God said, 'I did; I sent two rowing boats and a helicopter. ' (Joko Beck, 1997, p. 21) Conflicts and problems involving religious and spiritual beliefs, practices, and experiences can add to the development of challenging therapeutic issues. Whereas religious and spiritual beliefs may be part of the solution, they too can be part of creating clients' presenting problems or conflicts (Cashwell & Young, 2005). Problems involving religion and spirituality can manifest in various ways. According to Harper and Gill (2005), religious and spiritual practices can obstruct one's "recognition and resolution of emotional and relational difficulties" (p. 36). Sadly, some spiritual and religious beliefs and practices can be harmful and even destructive. Harper and Gill (2005) propose that when a person ascribes complete or disproportionate responsibility to religion and/or spirituality for issues that go beyond those beliefs and practices, spiritual bypass may occur. Accordingly, spiritual bypass provides vindications for individuals to evade responsibility and action. This also absolves the individual from experiencing immediate emotional distress. Consider the following example of Zoey. This is a classic illustration of spiritual bypass as Zoey abdicates personal responsibility though religious and spiritual fixations, minimizing her need to work on her familial relationships. 59 Clinical case illustration. Zoey, who was raised in a Jewish home and still practices Judaism, has come to couples counselling by the insistence of her husband, Aaron, because their relationship has been deteriorating. Through discussions with Zoey it appears this is true of many of her relationships. Zoey increases her religiosity and spirituality when life gets difficult. For example, she engages more in prayer, reading scripture and spiritual texts, and by frequently attending her local synagogue. Zoey admits that her increased religious activity gives her adequate excuses to avoid dealing with her husband or other family members. Accordingly, Zoey's relationships continue to deteriorate as her increased religious and spiritual activities leave little time for her family. Understandably Aaron believes this avoidance increases the tension in their marriage and in other familial relations. Because Zoey feels her religious and spiritual beliefs, practices and experiences are constructive, she justifies her activities, insisting they help. Moreover, Zoey maintains that as she places greater faith in Hashem and strives to be closer to Him, He will take care of her problems. Zoey further feels her increased religiosity has effectively reduced her emotional distress because of her faith that her relationships are in better hands. Though this discussion and others, Zoey's counsellor comes to realize she is engaging in spiritual bypass. Being careful not to undermine Zoey's beliefs, practices and spiritual experiences, her counsellor can help her decide how she can accept more personal responsibility for her relational difficulties. For instance, in discussing spiritual bypass, Harper and Gill (2005) make it clear that clients should be encouraged to maintain satisfying levels of involvement in their religious and spiritual activities while working on minimizing spiritual bypass. In the case of Zoey, her 60 counsellor might be most effective by encouraging Zoey to continue her religious/spiritual practices but give Zoey tools and encouragement to address the issues in her life that are problematic and find balance. Spiritual bypass may be manifested in other destructive ways as well. One expression of spiritual bypass described by Harper and Gill (2005) is that of inhibiting unwanted feelingsrepressing common feelings that are thought to be negative- may be one way spiritual bypass is expressed. Other examples they describe include: (1) habitual generosity-giving excessive time and possessions to religious or spiritual cause; (2) religious and/or spiritual superiority-feeling more enlightened or superior because of religious/spiritual beliefs, practices and experiences; (3) spiritual experimentation-religious and/or spiritual window shopping always looking for something more; and (4) blind faith in religious and spiritual leaders-following religious/spiritual teachers not because of one's own convictions but because those in authority demand it. These authors advise counsellors to consider potential issues of spiritual bypass to determine how religion and spirituality might be perpetuating the development or intensification of destructive beliefs and practices. Counsellors are asked to be respectful of individuals' religious and spiritual beliefs and behaviours; however, this respectfulness has limitations when such beliefs and behaviours tum violent and damaging. For example, committing terrorism, oppressing and abusing others in the name of a religious tradition or ideologies, including women and children, are all instances of destructive religious or spiritual beliefs. Counsellors concern for others must compel them to act to prevent harm. More importantly, legal and ethical mandates to protect others compel counsellors to act when religious or spiritual beliefs put clients or others at risk. As an illustration, according to CCAP (2007) code of ethics: "When counsellors become aware of the 61 intention or potential of clients to place others in clear or imminent danger, they use reasonable care to give threatened persons such warnings as are essential to avert foreseeable dangers" (p. 7). There are other less explicit ways in which unhealthy spiritual or religious beliefs may hinder a client's progression. In their study on the ethics of prayer, Weld and Eriksen (2007) suggest that clients may act out their problems religiously. As an illustration, an uninformed clinician may aggravate pathology by praying with a client who compulsively prays as an idiom of religious obsession. Consequently, any intervention which encourages clients to adhere to harmful spiritual or religious practices may interfere with attention to clients' central problems. Lovinger (1996) provided ten indicators of "probable religious pathology" and five indicators of mature religious adjustment (see Table 3.4). These indicators are useful in helping clinicians in assessing client's religious and spiritual beliefs. Table 3.4 Indicators of Healthy and Unhealthy Religious and Spiritual Beliefs "Probable religious pathology" Mature religious adjustment 1. Self-oriented or narcissistic displays 2. Religion used to gain rewards from God 3. Scrupulosity in avoiding sin or error 4. Relinquishing responsibility for problematic behaviour to "the devil" 5. Ecstatic frenzy or intense emotionality 6. Persistent church shopping 7. Inappropriate sharing of one's religious expenences 8. Religiously inspired 'love ' that causes pain or confusion 9. Using the Bible to answer ' ordinary questions about daily living' 10. Reports of possession by the devil 1. Awareness of complexity and ambiguity in the Bible and faiths more generally 2. Religious affiliation based on a thoughtful decision-making process 3. Value-behaviour congruence 4. Recognition of one's shortcomings 5. Respect for boundaries (Lovinger ,1996, p. 347-349) . - - - - - - - - - - - - - - -- ----- - 62 To further affirm how religious and spiritual beliefs, practices and experiences can lead to unhealthy and destructive patterns reflect on the following clinical case illustration ofHallmar. Clinical case illustration. Hallmar is working with the Meng family who are very conservative Buddhist; he first became involved through a school referral for Ying, who is 9 years old, because of attention deficit and hyperactivity behaviours. Hallmar learns the parents refuse treatment of various medications because their traditional beliefs dictate that western medications weaken the body and should be avoided; they instead prefer to use traditional Eastern medications. As such they refuse to use medications designed to treat Type 1 diabetes of which their son was recently diagnosed. Hallmar learns that Ying's doctors think he can easily live a normal life with medical intervention, but his health will likely deteriorate quickly leading to death rather soon without proper medical treatment. The family is insistent that Traditional Chinese Medicines will work; however, no improvement has been noticed by the family or reported by the boy's doctors. Although Hallmar strives to be respectful for the parents' beliefs and religious traditions, he cannot condone the disregard for the well-being ofYTng. More importantly the law requires Hallmar to report cases of or suspicion of child abuse or neglect to child protective services even though the Ying's doctor should have already filed a reported. Clearly this case falls under this mandate, even if the unintentional abuse or neglect is ')ustified" based on religious or spiritual reasons. According to the limits of confidentiality, Hallmar has the responsibility to report to child protective agencies the parents' decision to refuse the recommended medical treatment for Ying. 63 Developmental Readiness Religion and spirituality in terms of human development may best be described as dynamic declarations that are neither static nor rigid but are evolving, profound, and reflective aspects of human personality (Burke et al., 1999). It is clear that for many people, religion and spirituality are an integral part of their life development and occur in important ways at all developmental levels. Burton and Bosek (2000) in contemplating religion and spirituality development, suggest individuals' religious and spiritual beliefs, practices and experiences typically develop and mature over time. As a consequence, counsellors need to learn to distinguish between mature and immature religious and spiritual beliefs. Weld and Eriksen (2007) emphasize that such analysis can be accomplished by assessing to what degree clients beliefs "enable autonomy and foster successful conflict resolution" (p.l 02). Equally important, promoting client welfare and circumventing harm requires counsellor to ensure the developmental suitability of religious and spiritual interventions. Burke et a!. (1999) discuss the importance of including developmental readiness of clients. They explain that there are two main approaches that should be considered. First, clinicians should consider the relationship between human development domains (e.g., cognitive, emotional, moral, psychosocial, etc.) and the development of religious and spiritual beliefs, practices and experiences. As an example, the individual who has sufficient cognitive maturity to ask existential questions such as, "what is the meaning of life?" or "what is my purpose in life?" but lacks religious or spiritual development may cause clients to "experience free-floating anxiety and spiritual distress as unanswered questions open an inner door to self-doubt and meaninglessness" (Burke et al., 1999, p. 252). 64 Religion and spirituality can be considered a facet of life span development. Children and adolescents are just as prepared, if not more so, to explore religion and spirituality. More importantly, children and adolescents too experience religious and spiritual issues. Miller (2005) reports that such issues include: (a) dealing with death; (b) self-control; (c) coming to know and understand a God image; and (d) psychosocial interactions. In a similar way adolescents through young adulthood are faced with their own religious and spiritual issues. These may include aspects of identity, sexuality, alcohol and illicit drug use to issues related to school and work, being single, in a relationship or married, to becoming a parent. These issues are important to consider as children and youth develop, watching for unhealthy beliefs and practices. Even if one chooses not to pursue religious or spiritual practices of their youth, people are influenced by those formative years. Burke et al. (1999) suggest considering religion and spiritual development through the scope of research and theory that focuses explicitly on religious and spiritual development. As an illustration, Fowler (1991) developed a six stage theory of religious development (see Table 3.5). This theory is an excellent source for counsellors to understand what may be typical as well as problematic religious and spiritual development among their clients (Miller, 2005). This model demonstrates how complex the relationship between biological, emotional and cognitive development, psychosocial experiences, and religious, spiritual and cultural influences are (Polanski, 2003). Fowler's model is further useful in that it closely parallels many psychosocial developmental stage models (e.g., Erikson's psychosocial development theory; Piaget's cognitive-development stage model). As an example, it addresses how experiences, challenges, nurturance, and time are all necessary for development in individual spirituality. Beginning in adolescence, individual experience and world view extends beyond family. Individuals are tuned to the expectations and judgments of significant others but do not have a firm grasp to maintain an independent perspective. Many adults never venture beyond this stage. Beginning in late adolescence or early adulthood the individual accepts responsibility for their own lifestyle, beliefs, attitudes, and commitments. These people embrace individuality, subjectivity and the power of one's own feelings and beliefs, developing self-actualization and a commitment to one's beliefs. Typically beginning in midlife this stage involves embracing and integrating opposites and polarities in one's life. (e.g., critical reflection in recognizing and exploring the social myths, ideal images, and prejudices built through family and religious traditions, ethnic groups and one's cultural heritage) Although reaching this stage is rare individuals are grounded in oneness with the power of a being or God. Such persons are devoted to overcoming division, oppression, and violence, and strive for effective response to a commonwealth oflove and justice; the reality of the kingdom of God. 6. 5. Faith Universalizing faith Conjunctive faith Reflective 4. Individuative- faith Conventional faith 3. Synthetic- Typical of children ages 3-7 years old. At this stage children engage in fantasy-filled cognitions and can be powerfully and permanently influenced by examples, moods, actions and stories by adults in their lives. Typically begins in school age children but can be seen in adolescents and adults. This person begins to internalize the stories, beliefs, and observances that symbolize belonging to his or her community. faith Projective Intuitive- BriefDescription 2. Mythic-Literal 1. Stage Fowler's Six Stages ofFaith Development Table 3.5 This includes those whose faith is unified in an unwavering commitment and devotion to others. Many individuals in this stage die at the hands of those whom they hope to change (e.g., Jesus Christ, Martin King Jr.) and are not fully honored until after death. While others are revered during their life (e.g., Mother Theresa). (Fowler ,1991) Failing to act and becoming passive due to the paradoxical understanding of truth gives rise to complacency or cynical withdrawal a possible product of this stage. From the reliance upon other's beliefs, individuals may either develop positive or negative religious beliefs. Then when conversion experiences occur at later stages in ones' life, the images formed in this stage may need to be reworked in some significant ways. The expectations and evaluations of others can be compellingly internalized, inhibiting future autonomy of judgment and action. Interpersonal betrayals may also lead to pessimistic despair about personal beliefs or false identification of a Deity or of spirituality. The danger in this stage is analogous with its strengths. Being excessively confident in one's beliefs and being critical of other's beliefs may lead one to recruit others into their own worldview with either positive or negative intentions. At this stage conscious or unconscious exploitation of the child's imagination may occur in the reinforcement of taboos and moral or doctrinal expectations. Possible Dangers 65 66 Miller (2005) cautions that developmental models like the one presented here be used in a flexible manner within client's cultural context. Models such as this one can aid counsellors in correctly assessing areas clients are struggling in, looking for connections between life struggles and one's religious or spiritual views. Conclusion Counsellors not only need to become aware of possible religious and spiritual issues experienced by their clients, but they should be competent in managing such issues in clinical practice. Some clinicians may think they can adequately work with clients by the mere fact that they themselves belong to a similar faith tradition. Such beliefs will limit the effectiveness counsellors might otherwise have. Additionally, countertransference issues often result from such views. Polanski (2003) emphasizes that counsellor understanding of his or her level of spiritual development begins with exploring one's awareness of the relationship between personal and professional experiences. In a similar way, as counsellors become assertive in embracing the diversity that exists within most religious/spiritual traditions they will more effectively serve varied religious and spiritual clients. Clinicians probably well remember their first clinical experiences, and the feelings that were associated-striving not to do more harm than good from the lack of knowledge and experience. But clinicians will also recall that no client was despairingly impaired by such inexperience. I suggest the same is true of integrating religion and spirituality. Counsellors do not need to know everything there is to know about successfully integrating religion and spirituality with clients. The first step to becoming competent is to acknowledge the importance religion and spirituality play in most clients lives. Young and Cashwell (2005a) suggest that being truly sincere and seeking supervision when needed will aid you in developing competency. 67 The final section of this guide is intended to help counsellors specifically assess religion and spirituality first in their own lives and then apply integrated religious and spiritual interventions in counselling practice. My objective is to provide ample discussion and tools for counsellors to become more competent and comfortable in this important realm. 68 Section 4. Religion, Spirituality and Counselling Practice: Guide to Therapeutic Techniques and Interventions Counsellor Self-Assessment Before counsellors can effectively incorporate religion and spirituality into clinical practice we need to assess where we stand on these issues; Corey et al. (2007) suggest this selfassessment must be done if we hope to gain a complete understanding of the beliefs, practices and experiences of our clients. This understanding must include not only our personal beliefs and practices but must extend to our beliefs about the effectiveness of including religion and spirituality in clinical practice. In a similar fashion, Polanski (2003) advocates for counsellors to become aware of their own religious and spiritual beliefs in order to effectively and ethically address their client's religious and spiritual issues. Moreover, this analysis can aid in explaining how one 's cultural background is linked to one's religious and spiritual worldview. Hagedorn (2005) explains that clinicians bring with them their life experiences, worldviews, morals, and personal relationships into the counselling process. Cashwell and Young (2005a) summarized it best in their concluding remarks: "Our responsibility to the clients with whom we work is to first and foremost do our own work, the work of both developing spirituality and staying grounded in this work" (p. 186). In their article on ethical values of"master therapists" Jennings et al. (2005) emphasize there are several important issues for clinicians to consider that will help them become more selfaware. They state that counsellors need to be aware of their personal emotional, physical and psychological needs and gain an awareness of their own "unfinished business, personal conflicts, defenses, and vulnerabilities" (Jenning et al. , 2005 p. 42). Most importantly, clinicians need to 69 have an awareness of any potential for these issues to intrude in counselling practice. This certainly includes the realm of religion and spirituality issues. Our value system influences every facet of our clinical practice. This includes assessment procedures, views of therapeutic goals, interventions and techniques utilized, topics explored within the therapeutic relationship, and even appraisals of treatment outcomes. As Corey et al. (2007) simply state "No therapy is value free" (p. 91). Understanding one's own value system may very well increase a counsellor's sensitivity to the values held by clients (Hagedorn, 2005). It is clear that counsellors' ability to meet their clients' needs may be compromised if they themselves do not meet their own needs through applicable sources (Jennings et al., 2005). As previously noted, we as therapists have an ethical responsibility to be cognizant of how our religious and spiritual views influence the therapeutic relationship and to ensure we are not inappropriately influencing our clients. Clinicians must assess their understanding of the client's religious, spiritual beliefs and worldview. It is imperative to gain such knowledge first because no religious or spiritual intervention can be viewed as therapeutic for clients before adequate assessments are done (Faiver & Ingersoll, 2005). Recommended Activities There are several appropriate activities found in the literature offered to help counsellors examine their religious and spiritual views. This section will discuss several recommended activities; for example, writing a spiritual autobiography, keeping a journal, interviewing a practicing clinician, getting exposure to religious and spiritual experiences, and the use of spiritual genograms . 70 Write a spiritual autobiography. Identifying substantial events that contribute to one's religious and spiritual perspective can be important for professional competence. Understanding one's religious and/or spiritual history and one ' s chosen tradition may be approached through the use of a spiritual autobiography. Developing a spiritual autobiography begins as an evolving examination of one's religious and/or spirituality and than develops to consider one's morals and whether those morals are mirrored in one's cognitions and behaviours (Faiver & Ingersoll, 2005). Writing a spiritual autobiography may also help counsellors view their childhood messages about religion and spirituality. As Curtis and Glass (2002) explain, this reflection "through adult lenses, helps [clinicians] to gain additional insight into the power of their previous experiences" (p. 5). In other words, a spiritual autobiography is a compilation of one ' s religious/spiritual history in written form. In writing about spiritual autobiographies, Frame (2005) suggested the following questions be asked: What are your earliest memories of religion and/or spirituality in your home or family life? Describe your experiences with religion and spirituality through childhood, adolescence, young adulthood, and beyond. Write about episodes when your religious or spiritual beliefs and values were challenged or changed. Reflect on where you are with religion and spirituality at this time in your life. Where are you with this aspect of your life now? What would you like to do regarding religion and spirituality in the future? (Frame, 2005, p. 23-24) These questions provide an excellent starting point for clinicians to explore when completing a spiritual autobiography. In the following table (Table 4.1) Faiver and Ingersoll (2005) propose an excellent format for developing one's religious/spiritual autobiography. These authors give suggestions for each step of the developmental process. .------ - - - - - - - - - - - - - - - - -- ---- . 71 Table 4.1 Proposed Autobiography Format Introductory In this statement use a sense of free association when responding. Any response statement: may be appropriate, including purpose and objectives for carrying out such an assessment, personal or professionally narratives, thoughts emotions, anything at all that bubbles to the surface. Spiritual themes Spiritual influences • • • • • • • • • Life lessons Personal conclusions • • • • • • How would you introduce your spiritual journey? How do you describe yourself with regard to religion and spirituality? What spiritual themes, topics, subjects, and so on permeate my life? What Jungian archetypes emerge, if any? Are there spiritual themes that set the tone of my life, either positively or ne ativel ? As I complete a look back at my spiritual development, who has influenced me? Are there major religious figures, prominent psychotherapists, and other major figures? Do I note mentors who have affirmed me? Are there certain friends and family on whom I can count for nurturance, caring, and comforting? As I complete the life review, influences, and themes, what lessons emerge? What personal and professional discoveries can I glean? What life lessons do I want to pass along to others? How do I intend to pass these lessons along? Finally, are there any conclusions regarding this exercise in selfassessment in this process of personal and professional discernment? Note any and all thoughts and feelings (Faiver & Ingersoll, 2005, p.175) The advantages to writing a spiritual autobiography include counsellors using this exercise to reflect on past experiences and reflecting on how their religious and spiritual experiences have influenced their spiritual development. Such investigation can lead to awareness of how one's spiritual development extends to impact other areas of life (Harper & Gill, 2005). This technique is not exclusive to clinicians; counsellors may find this exercise useful for many of their religious/spiritual clients in helping them gain deeper awareness and gleaning meaningful interpretations of their current and past experiences. 72 Journaling. Counsellors can develop greater spiritual self-awareness by keeping a spiritual journal. In much the same way that journaling helps clients, counsellors too can use journaling to assess where they stand regarding religious and spiritual issues. Counsellors can, for example, write about their religious and spiritual experiences and what might bias them in addressing such issues in clinical practice. As Fukuyama et al. (2005) suggest, spiritual joumaling allows for the free expression of thoughts and feelings, leading to reflection, and selfanalysis without fear of being judged by self or others. During this process counsellors can review their core beliefs and values, noting how such beliefs may have shifted over time and through circumstance. The following table (Table 4.2) contains possible questions that Frame (2003) suggested counsellors consider when writing in a journal regarding challenging life questions found through religion and spirituality. This activity is intended to help counsellors gain a better understanding of their own religious and spiritual views. Clients may also be struggling with similar questions regarding religious and/or spirituality. Accordingly, understanding where you stand on religious and spiritual matters will go a long way in providing help to your clients. Journaling can further help counsellors assess how they anticipate integrating religion and spirituality in the counselling process. In other words there are potential issues and concerns that might emerge (e.g., countertransference). Journaling can be utilized to answer questions such as, what challenges may emerge as you endeavor to evaluate your client's religious/spiritual realm? Which religious and spiritual assessment techniques and tools do you feel most appropriate for you and your clients? Through evaluating your own level of knowledge, understanding and confidence in addressing client's religious and spiritual beliefs, practices and experiences, how do you anticipate your ability to correctly assess this important domain in 73 Table 4.2 Journaling Questions • What is your view of human nature? Are people good, evil, neutral? • What about free will? Do people have the ability to make their own choices or are their thoughts, feelings, and actions determined by some other force such as instincts, reinforcements, God? • Why do bad things happen to good people? Who is responsible for evil? Is there an evil spirit that struggles against a good spirit? Is there a God who is powerless to contain evil? Do bad things happen to good people because the "good people" aren't really as good as they think they are? Do bad things happen randomly? • What happens to people after they die? What do you believe about afterlife? Describe it. • Do you believe in a Higher Power? What are the qualities of the Supreme Being if you believe in one? Why do you believe in a Higher Power or God? If you do not believe in a Higher Power or God, what are the reasons for your disbelief? • What is your understanding of spirituality? How have you experienced it in your life? • Where do you think you are most vulnerable to countertransference when clients raise religious or spiritual issues? What experiences have you had that lead you to believe that you are particularly vulnerable to "clinical triggers"? • Which types of clients or client problems involving religion or spirituality would be the most challenging for you? Why? Which ones would be most exciting? Why? (Frame, 2003, p.32-33) clients' lives? And in what ways do you anticipate your personal views encouraging certain beliefs, practices and experiences over others (Harper & Gill, 2005)? Although these questions may not be easy to answer, considering them will provide added awareness for the competent counsellor. Seek supervision and consultation. Obtaining clinical supervision regarding religion and spirituality in clinical practice might very well be one of the most important steps counsellors engage in. Through supervision, client care is monitored and counsellors are aided in enhancing their professional competency. In this way, supervisors ensure clients are being 74 cared for in a holistic manner which includes consideration of areas of religion and spirituality. This also ensures counsellors are being trained and are enhancing their skill and knowledge. Equally important, supervisors can acquaint supervisees on ethical guidelines and codes that relate to religious and spiritual clients and client issues. Counsellors demonstrate competency through the training, experience, consultation and supervision they receive in their work with religious and spiritually informed supervisors (Aten & Hernandez, 2004). Aten and Hernandez (2004) report there are several areas that could be addressed during supervision to increase counsellors' religious and spiritual integration competency; in fact, they suggest that counsellors should be competent in eight domains to work effectively with religious and spiritual issues with clients. These areas include: (a) competency in intervention skill utilization; (b) assessment procedures; (c) self-assessment; (d) assessment of client religious and spiritual needs and values; (e) clinician and client personal and cultural similarities and differences; (f) clinical orientation; (g) treatment plans and goals; and (h) ethical considerations. Although these domains are viewed as starting points, as supervisors and supervisee's work to incorporate all eight of these competencies in clinical supervision, higher competency levels can be reached. Spiritual genogram. Counsellors bring with them their worldviews, life experiences and personal relationships into the counselling process, therefore it is suggested that during supervision supervisors encourage supervisees to complete some family-of-origin work. During supervision, for example, it may be beneficial for counsellors to construct a spiritual genogram (described later in detail under the heading Religious and Spiritual Assessment). The spiritual genogram is a process that "enables people to gather intergenerational data about their religious and spiritual traditions, practices, beliefs, and experiences" (Frame, 2001, p. 114). According to 75 Frame (2001) the spiritual genogram can also assist clinicians in increasing self-awareness of how religious and spiritual issues in their own families could affect their efficacy in working with clients. Constructing a spiritual genogram may also aid counsellors in connecting with their families of origins, help them learn significant information from the past, and provide an impetus for renegotiating relationships in the present-day. This information can be gathered from one's own recollections and knowledge, and from parents, siblings, grandparents, aunts and uncles and cousins; face-to-face contact is preferable (Frame, 2001). As supervisors work through the spiritual genogram with their supervisees, several questions may be appropriate to enhance greater self-awareness. The following questions found in Table 4.3 were put forward by Frame (200 1) and are utilized here to provide additional significance and insight to counsellors. Clinical case illustration. Olivia has been working with a highly religious client for a short period of time and has realized she is becoming increasingly agitated by this client's constant reference to scripture and religious doctrines. She has briefly discussed this discomfort with her supervisor Ava and they arranged to discuss this in more depth during their weekly supervision meeting. Knowing she needed to assist Olivia in gaining an understanding of potential religious and spiritual issues, Ava prepared several techniques Olivia could engage in to increase her awareness and competency. During supervision Ava helped Olivia explore her own religious and spiritual beliefs. Olivia, who sees herself as an agnostic, could not attribute her negative feelings toward anything specific. Seeing Olivia apparently stuck, Ava introduced the spiritual genogram and encouraged Olivia to complete the spiritual genogram for their next supervision meeting. 76 Table 4.3 Spiritual Genogram Questions Areas of inquiry Potential questions Role of religion/spirituality What role, if any, did religion/spirituality play in your life when you were growing up? What role does it play now? Specific beliefs and practices What specific religious/spiritual beliefs do you consider most important for you now? How are those beliefs a source of connection or conflict between you and other family members? Religious/spiritual rituals What religious/spiritual rituals did you participate in as a child or adolescent? How important were they in your family of origin? Which ones do you still engage in? Which ones have you let go? What new rituals have you adopted as an adult? How do these rituals connect to your religious/spiritual beliefs system? Multicultural influences What view did/does your religious/spiritual tradition hold about gender? About ethnicity? About sexual orientation? How have these beliefs affected you and your extended family? Historical and current religious/spiritual patterns What patterns of behaviour and relationship resulting from religion/spirituality emerge for you as you study your genogram? How are you currently maintaining or diverting from those patterns? Your views in relation to clients How does your religious/spiritual history connect with your attitudes toward working with clients' religious/spiritual issues? What new insights or concerns occur to you based on discoveries made through the genogram? (Frame, 2001, p. Ill) The following week Olivia returned feeling relieved through a greater sense of understanding resulting from the completion of the spiritual genogram. Through consulting with her parents and a grandparent, Olivia learned where much of her negative feelings toward religion came from. She explained to Ava that when her paternal grandfather was a young man, he was a minister for the United Church. After three years 77 as a faithful parishioner he was excommunicated on allegations that he sexually molested a child, but was later acquitted of all charges. However, her embittered grandfather never returned to the church and forbid his entire family to step foot into the church again. She also learned that her maternal grandparents were devout Episcopalian but after ten years of marriage, left the church because of the actions of other church members. They too refused to let their children be involved in the church. In learning about her family's negative experiences with religion, Olivia reported that she better understood her reluctance to engage in religious conversations with clients as it created an inner conflict for her. Olivia reported that in some way, she felt she was betraying her family by discussing religion and spirituality with clients. Through this and other self-assessment and self-examination techniques employed by Olivia and Ava, Olivia now feels more comfortable engaging with clients' religious and spiritual issues. She also reports that she is more willing to learn about the ways clients perceive and use religion and spirituality as positive influences in their lives. In this example, it could have been easy for Olivia to ignore other points of view and insist that what she was feeling was right. In a similar way, Ava could have focused supervision solely on the client, analyzing why the client felt the need to use religiosity to function. Consider the following questions: What other self-assessment procedures could Olivia explore? If you were in a similar situation how do you suspect your religious and spiritual similarities and differences that you experience with your clients will affect your clinical work? Like Olivia, what potential religious or spiritual issues raised by your clients concerns you, based on your family history? Excommunicated J Explores various forms of spirituality Considers all religion destructive _j Dylan 1964 Left church when husband excommunicated M. 1937 Figure 4.1 Olivia 's Spiritual Genogram ~ Olivia 1966 ~ M. 1942 Passed away as a child D m ~ No Religion Agnostic Atheist 1::}:\:/l Episcopalian ~ United Church Married Jehovah's Witness ~ Shona 1946 Grew up in religious home but became disgruntled when parents did ~ Left church with wife Counsellorunknowingly took on family perceptions M. 1961 ~ ~~ :-: :-: :·X9J8?·:::-: :-: .. ... ..... . Had dispute with Minister & other church members; left church Never had connection to God but feels spiritual ~~ 11\ 78 79 Consult competent professionals. Another valuable way to gain competency is to consult with someone who is currently working in the mental health field providing direct counselling service that includes the integration of religion and spirituality when required. I suggest clinicians interview such counsellors regarding issues raised in this guide and ask other questions one may have regarding integrating religion and spirituality in clinical practice. Consider using some of the questions provided below to assist your consultation (see Table 4.4). Consulting with a counsellor more experienced in integrating religion and spirituality or even in general practice can provide additional opportunities to learn how to word questions to religious and spiritual clients that facilitates empathy and increases the therapeutic relationship (Yarhouse & Fisher, 2002). Table 4.4 Interview Questions • How do you understand the differences between religion and spirituality? • • If you do address religion and/or spirituality in your work with clients, what is your reason for doing so? How would you describe your own spiritual path if you have one? • Which type of clients or client problems involving religion or spirituality would be the most challenging for you? Why? Which ones would be the most engaging? Why? What is your opinion about working with clients' religious or spiritual issues in counselling? How comfortable do you feel in doing so? • How does your theoretical orientation to counselling contribute to your approach to working with clients' religious or spiritual issues? (Frame, 2003, p.32-33) 80 Consulting with competent collogues regarding religion and spirituality may not always be possible or adequate. For instance, counsellors working with several clients from a given religious group may want to consult clergy to not only create a positive working relationship, but to gain valuable insights into their specific beliefs and practices. In other religious or spiritual realms, counsellors may consider spending time getting to know the religious or spiritual culture by being an active participant or passive observer. For example, attending First Nation's sweat lodges and potlatches if invited or consulting with Elders may give counsellors added insights to help their First Nations clients who practice traditional First Nations spirituality and/or to better understand family of origin issues. Consulting experts in their respective religious or spiritual dogma may shed light on specific doctrines, beliefs, and practices that specific religious or spiritual groups adhere to. This consultation provides the counsellor with an understanding of whether the client's beliefs are customary for the religion/spiritual tradition or if they are extreme and self-justifying (Basham & O'Connor, 2005). It would be hard if not impossible for counsellors to help their clients work toward religious and spiritual development and transformation without first developing their own knowledge and understanding of religion and spirituality both personally and professionally. It is also evident, as Polanski (2003) explains, that the religious and "spiritually competent counsellor engages in self-exploration of his or her religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of his or her belief system" (p. 13 7). Through engaging in self-exploration activities such as writing a spiritual autobiography, keeping a journal about one's religious and spiritual beliefs, practices and experiences, consulting with 81 competent colleagues and seeking supervision, counsellors are well on the path to successfully integrate religion and spirituality. Case (1997) further suggests that counsellors participate in some form of counselling themselves to gain a greater awareness of the motivation behind their religious and spiritual thoughts, feelings and behaviours. I might add that addressing one's own religious and spiritual beliefs, practices and experiences during personal therapy will not only provide counsellors with a greater awareness of their own religious and spiritual issues but will put them more in touch with what their clients may be experiencing when addressing such issues in session. Religion and Spiritual Assessment Through self-exploration activities counsellors can become better prepared to work with clients' religiosity and spirituality; however, having the appropriate professional skills and techniques to integrate religion and spirituality in clinical practice is equally important. Remember the vast majority of Canadians and Americans consider religion and spirituality to be an important part of their lives and want health care providers to address religious and spiritual issues (Townsend et al. , 2002). For this reason and others counsellors need to become competent in assessing religious and spiritual issues. Religious and spiritual assessment is defined as the process of eliciting the religious and spiritual history of clients; this also includes determining the amount of value or importance clients assign to religion and spirituality. Religious and spiritual assessment should happen within the expansion of the clinical assessment. Just as Oakes and Raphe! (2008) indicate, religion and spirituality are often great sources of strength for clients and can be used to overcome psychological difficulties. More specifically, religious and spiritual assessment can be 82 used to understand clients' world views and gain awareness of clients' context. In other ways such exploration may be used to encourage client self-exploration, to assist clinicians in diagnosis and help uncover potential religious and spiritual problems, to help clients utilize their religious and spiritual resources, and assist clinicians in determining which interventions might be suitable (Greggain, 2009; Harper & Gill, 2005). Religion and spirituality is one aspect of human nature and there are potentially significant positive and negative religious and spiritual influences experienced by clients. Many of these influences stem from one's own values and from genealogical beliefs passed from generation to generation influencing emotional and cognitive well-being. Oakes and Raphel (2008) report there are several things a religious/spiritual assessment should include. They suggest the following: (a) consider historical religious and spiritual values, beliefs, practices and experiences; (b) explore clients' religious and spiritual community participation; (c) encourage discussions about and descriptions of clients' God image; (d) evaluate clients' religious and spiritual practices including prayer, mediation, reading religious and spiritual texts, congregational gatherings, and other spiritual and religious rituals; and (e) seek clarification about the beliefs, practices and experiences clients have. It is important to recognize that when completing a religious or spiritual assessment, the goal is neither to pathologize clients' beliefs nor should the goal be to determine if such beliefs are right or wrong (Stanard et al., 2000). Instead a full religious and spiritual assessment is used to determine how clients' beliefs and practices can be used as positive coping and problem resolution techniques . The purpose of this section is to provide counsellors with valuable information, guidelines, techniques and assessment tools to competently work within a holistic perspective. 83 Process Guidelines Just as counsellors work hard to asses their clients needs, values, assumptions and strengths through assessment procedures, they too must work hard as they integrate religion and spirituality assessment procedures. For those who include or wish to include religion and spirituality as part of a holistic orientation, one needs to be cautious of how their own framework or values might be used to calculate the health and maturity of their clients' religious and spiritual beliefs. To begin the process of integration counsellors should "explicitly and humbly acknowledge (to themselves and their clients) the theological biases that influence, and may even ground, their diagnostic and assessment frameworks" (Slife & Richards, 2001, p 203). Through maintaining this open dialogue between therapist and client, counsellors can ensure an effective and ethical therapeutic relationship will ensue. This may also be helpful in reducing the risk that assessment procedures and evaluations made by clinicians are relevant and provide a fair evaluation of the religious and spiritual maturity and health of clients. Establishing a therapeutic relationship. The importance of the therapeutic relationship has been extensively written about elsewhere (Corey et al, 2007); however, my purpose here is to stress the importance of first establishing a healthy working alliance with clients before the subject of religion and spirituality can most effectively be approached. Egan (2007) maintains that counsellors and clients are collaborators in achieving a working therapeutic relationship. This collaborative relationship pivots on the assumption that counsellors and clients work together in "problem-management" and 'opportunity-development" (Egan, 2007, p. 50) related to therapeutic outcomes. This certainly includes the counsellor's willingness to be flexible in the relationship. In relation to religion and spirituality, this means counsellors first need to be willing to explore such issues. Second, counsellors need to be willing to "use a mix of styles, skills and 84 techniques tailored to the kind or relationship that is right for each client" (Egan, 2007, p. 50,). And third, counsellors need to show upmost respect for client's religious and spiritual perspectives. This includes doing no harm, becoming competent and committed, assume the client's goodwill, do not rush to judgments, keep the clients agenda in focus , and make it clear that you are there for your clients (Egan, 2007). It is through the therapeutic relationship in the early stages of counselling that clinicians gather relevant information about a client's religiosity and spirituality. Working within clients' framework. Another challenging issue for including religion and spirituality in clinical practice is making sure one is working within their clients' framework. This means that counsellors actively strive for greater awareness about the theological foundations of the religious and spiritual goals and interventions utilized. Furthermore, counsellors work hard to not push clients in certain directions. Simply stated, if religion/spirituality is important for clients, than it is essential for counsellors to explore such issues with clients (Egan, 2007). Remember religion and spiritual discussions can easily lead to countertransference as previously noted. Such discussions can also raise potential ethical issues; nevertheless, when counsellors strive for professionalism and work within their client's framework, a strong therapeutic alliance can be born, leading to deeper understanding by the counsellor and potential change for the client. For me, Corey (2007) simply and eloquently summed it up best: "By not raising the issue [of spiritual and religious values], clients may assume that such matters are not relevant for counseling, and counselors may be guilty of excluding an important issue of diversity" (p. 88). He went on to say, "Spirituality and religion are critical sources of strength for many clients and provide the bedrock for finding meaning in life" (Corey, 2007, p. 88). Working within clients ' 85 religious and spiritual framework will best be accomplished as counsellors remember that such matters are therapeutically appropriate, ethically applicable and potentially important in secular counselling. Assessing Clients Religious and Spiritual Needs Just as client assessment should include a comprehensive review of past and current functioning of circumstances, affect and behaviours, religious and spiritual assessment should in the same way consider how clients' beliefs, practices and experiences influence their lives. Even though a client may consider him or herself as never being or no longer being religious or spiritual, a background of involvement in religion and spirituality needs to be considered as part of the client's history (Corey, 2007). Although types of assessments vary across different counselling fields (e.g., mental health, school counsellors, etc.), the initial assessment in many ways can be similar for all counsellors, giving them important information and insights, and creating the environment for consequent contact (Faiver & Ingersoll, 2005). To be clear, understanding clients' concerns will best be accomplished through gaining an awareness of how the client's values and beliefs are connected to the concerns that bring the client to counselling. Intake procedures. The assessment of clients' religious and spirituality can easily begin during the initial intake interviews. Stanard et al. (2000) report that questions regarding religion and spirituality be included as a regular part of intake procedures and incorporated into the initial phases of counselling. Exploring this dimension early in the counselling process, they suggest, will not only provide added information and insight for counsellors that can set the stage for a more formal assessment later, but will also indicate to clients that such exploration is acceptable during the counselling process. Faiver and Ingersoll (2005) suggests that a religious and spiritual 86 assessment begin with the global and conclude with the specific. In other words, counsellors should be sensitive to the reluctance some clients might have in discussing religion and spirituality as many hold these values and beliefs closer than most other values and beliefs. During the intake interview counsellors can, as most do, explain to their clients that the intake process is about obtaining adequate information so their wants and needs can best be met. Religion and spirituality can naturally be addressed in the discussion. The counsellor can, for example, simply ask if the individual considers him or herself a religious or spiritual person. Whether they answer yes or no, follow-up questions can be asked to determine to what extent they have internalized their answer. Or, counsellors can ask if the client would like to discuss religious or spiritual issues within the counselling relationship (Dunne, 2008). Either way, clients are given the message that discussing religion and spirituality during counselling is acceptable. Timing is a critical consideration, as Oakes and Raphel (2008) suggest; religion and spirituality tend to be deeply private, personal and sensitive for many clients. Remember that the intake process is used for basic information gathering, while during the formal assessment process more in depth questions can be addressed. During the intake process keep religious and spiritual question basic and nonintrusive. Table 4.5 provides several questions posed by Fukuyama et al. (2005) that may be appropriate to ask during the intake process. Assessment procedures. There are several techniques that can be employed to aid counsellors in obtaining relevant religion and spirituality information that influence clients. In many ways the basic therapeutic techniques (e.g., active listening, empathy, probing, summarizing, paraphrasing, etc.) counsellors utilize everyday during practice will go a long way in drawing out client information regarding their previous and current beliefs, practices and experiences with religion and spirituality. 87 Table 4.5 Intake Questions Focusing on Religion and Spirituality Do you have a religious or spiritual • Do your parents have a religious/spiritual preference, and if so, how important is it to preference? them? • Do you currently attend religious services • What religious/spiritual rituals did you or participate in spiritual observances? If participate in as a child or adolescent? so, how often? On a 10-point scale, with 10 being • How important were they in your family of extremely important and 1 being not origin? important, how important are your Which ones do you still engage in? religious and/or spiritual beliefs to you? • Which ones have you let go of? • How does your faith give your life • In what ways do you want to include meaning? religion/spirituality in our counselling Who can support you so that you can grow sessions? in your faith in helpful ways? • How do you see your religious/spiritual beliefs contributing to your understanding (Fukuyama et al., 2005, p. 136) of your current problem or solutions? However, at times it is useful to have specific techniques and strategies available to assist in the assessment process. For example, utilizing specific questions that can lead to discussions about clients' religious and spiritual orientations, using spiritual genograms, providing assessment forms for counsellors and clients to explore, and having specific assessment indexes and scales available, may be appropriate for the assessment process. It is through a comprehensive assessment that a more informed decision about the appropriateness of creating a treatment plan that integrates the client's religious and spiritual views can be made (Corey, 2007). Harper and Gill (2005) have written on assessment techniques utilized as part of religion and spiritual integration. As in most assessment processes, there are both qualitative and quantitative methods available for religious and spiritual assessment. There is no fast and hard rules about which type should be used and when. Instead counsellors are encouraged to use the techniques that are best suited for their type of work and that jive well with clients. There are 88 advantages and disadvantages for both qualitative and quantitative assessment measures. Qualitative assessment techniques, for example, are designed for exploration in a flexible manner. Qualitative assessments can be interventions in of themselves and other advantages include the use of varied terminology and the focus on strengths (Harper & Gill, 2005). Qualitative assessment techniques include things like behavioural observations, religious and spiritual histories and interviews, religious and spiritual autobiographies, and spiritual genograms. Conversely, quantitative assessment measures typically have psychometric properties for quantifiable means and tend to be more focused. Quantitative assessments give quantifiable results which may be comparable to larger populations. A set number of themes are presented and administering a quantitative assessment is usually time efficient (Harper & Gill, 2005). Quantitative assessments may be limited by the terminology used, current condition of the client (i.e., if the client is having a bad day or does not fully understand the language used), the measures may miss valuable information relative to the client, and such measures can be misinterpreted. It is strongly suggested that when quantitative assessment measures are employed, adequate training in the instrument be conducted, and clients be appraised of the purpose of the instrument and ultimately be given the opportunity to decide if the findings are an accurate reflection of their personal beliefs (Harper & Gill, 2005). Ideally, counsellors should employ a mixture of qualitative and quantitative assessment measures as they assess their client's historic and current religious and spiritual beliefs, practices and experiences. The following pages will provide some examples of both types of assessment procedures. 89 Qualitative Assessment Techniques Assessment questions. As the therapeutic relationship matures and evolves, in-depth assessment questions may be developed to obtain a greater awareness of a client's religious and spiritual influences. In accordance with Oakes and Raphel's (2008) suggestions, as much as possible, the assessment questions counsellors employ regarding religion and spirituality should be related to the client's presenting problems. Logically, counsellors should ask questions about how religion and spiritual beliefs, practices and experiences might be related to the client's cognitive, affective and behavioural processes (Corey, 2007). Possible questions may include, "How has your childhood influenced your present religiosity/spirituality?" "What has been the most profound religious/spiritual experience you have had?" "How does your religious/spiritual walk help you cope with everyday challenges?" "Do you pray? If so how effective do you feel it has been in your life or the lives of your family?" "Have there been times in your life when you were satisfied that your prayers were not answered or answered differently than you wanted?" "What questions would you like to ask God/higher power?" "What questions do you thing God/higher power would like to ask of you?" Oakes and Raphel (2008) explain that additional questions focusing on religion and spirituality may pertain not only to family religious/spiritual affiliations and familial historical religious/spiritual rituals, but may also include discussions on how religion/spirituality has been used by one's family to cope with life's challenges and difficulties. This could also include discussions regarding family conflicts resulting from differing religious and spiritual beliefs to also include what roles extended family members play in the client's religious and spiritual development. As the therapeutic relationship becomes stronger, counsellors can utilize these questions to elicit deeper discussions and find greater meaning in clients' lives. However, 90 additional assessment procedures can help counsellors obtain specific information about clients' religion and spirituality that might otherwise be ignored, forgotten or simply passed by. Spiritual genograms. As religious and spiritual issues surface during counselling, therapists can construct a spiritual genogram with his or her clients. Even if some counsellors feel uncomfortable with including religion and spirituality in clinical practice, the spiritual genogram provides a therapeutic technique that can effectively investigate this important area of clients' lives and familial relationships. Spiritual genograms are similar to genograms counsellors often utilize in individual, marriage and family counselling. Frame (2000) suggests there are four steps involved in creating a spiritual genogram. These consist of: (1) construction of the spiritual genogram; (2) providing in depth questions for further exploration; (3) helping clients connect with their family of origin; and (4) using the spiritual genogram as an integrative tool as part of therapy. As a genogram relates to religion and spirituality it is "a multigenerational map of family members' religious and spiritual affiliations, events and conflicts" (Frame, 2000, p. 211). This tool assists clinicians and clients in exploring clients' religious/spiritual heritage, looking for ways generational beliefs, practices and experiences impact one's present issues; it also includes the opus and organization of the client's family and the emotive and interactive methods ofthe family (Frame, 2001). This tangible representation can be a useful assessment tool considering the structural, relational, and functional information about a family both horizontally across the family context and vertically through the generations (McGoldrick & Gerson, 1985). Because spiritual genograms are blueprints into one's family history, their utilization can be presented during any part of the therapeutic process. However, Harper and Gill (2005) suggest a spiritual genogram be started during assessment, if it is deemed beneficial. Then as therapy progresses, 91 information can be included as clients provide greater detail. In short, the spiritual genogram helps clients gain a better awareness of how their religious and spiritual history perpetually affects their current functioning. Characteristically, genograms are tangible graphic representations that include a description of the client' s two or three preceding generations, the client's generation, and any subsequent generations (Limb & Hodge, 2009). Demographic information including births, deaths, marriages, divorces and remarriages are represented; the genogram may also include familial relationships (e.g., alliances, conflicts, cutoffs, enmeshment, disengagement, etc.) (Nichols, 2009). Depending on the information available and obtainable, the genogram may need to be adapted to fit such dynamics such as the client's knowledge of genealogical factors to the significance of certain information relative to the current clinical issues (Harper & Gill, 2005). This includes important information relative to religion and spirituality such as, baptisms, first communions, confirmations, bar and bat mitzvahs, religious/spiritual wedding ceremonies, funerals, and other relevant rituals and rites of passage. Additionally, indicating conversions, excommunications, and leaving a religious/spiritual organization or movement can add depth and meaning related to the stability or mutability of the client' s family religious/spiritual connection (Frame, 2000). Spiritual genograms should include symbols depicting religious/spiritual closeness, differences, and "rebellions" within the family between family members. For example, a conflict between a mother and daughter when the daughter decides to marry outside her religious tradition should be indicated. Frame (2000) further suggests that significant events (e.g., building projects, death of a beloved religious/spiritual leader, a congregational relocation, sexual misconduct of religious/spiritual leader, closing of a church, synagogue, mosque or other 92 religious or spiritual centre, etc.) in the religious/spiritual community be added in a spiritual genogram. Constructing a spiritual genogram can be used in conjunction with the assessment questions that were previously discussed. Then follow-up questions can be used to elicit specific information regarding the client's spiritual genogram (see previous Table 4.3); these questions can ether be explored during session or given as a homework assignment. Then during subsequent sessions, clients' answers can be discussed and indicated on the spiritual genogram. As some of the historical religious/spiritual information may not be known by the client, counsellors can encourage their clients to complete the genogram through face-to-face conversations with family members. This interaction can be therapeutic in its self; such contact can enable clients to not only obtain the desired information but can also help to renegotiate relationships in the present (Frame, 2001 ). Utilizing this technique can be generalized to all religious/spiritual orientations. However, as with other assessment procedures and techniques, constructing a spiritual genogram with culturally diverse clients needs to be adapted to meet each client's needs. With this awareness in mind, Limb and Hodge (2009) conducted a study looking for ways the spiritual genogram could be adapted to culturally diverse groups, specifically Native American individuals and families. They suggest that from a Native American perspective, spiritual assessments are necessary to ensure a proper balance in mental health is kept. Native Americans as with other diverse cultural groups, for example, often have a broader definition of extended family and may view spirituality traditionally, often using fewer Biblical references such as, denomination, worship, and church. As such, the spiritual genogram needs to be tailored to hold meaning for such individuals. 93 The purpose of constructing a spiritual genogram with Native American clients is two fold according to Limb and Hodge (2009). They explain that the spiritual genogram considers both the historical components and the present spiritual functioning of clients. Furthermore, the questions asked and the way they are asked is very important. They established, for example, that many Native American experts advise that spiritual genogram questions be kept to a minimum, be concrete and very open ended allowing for story telling. They further found that using correct words when posing questions be culturally relevant. They recommend using works like "cultural values" and "beliefs," "tribal affiliation" or "ceremonies" and advise avoiding words more associated with the Bible and other teachings. In their conclusion Limb and Hodge (2009) provide several applicable spiritual genogram questions that are culturally sensitive and relevant to Native American clients. Table 4.6 provides a summary of many of these questions. Clinical case illustration. Over the past few months Paige has been working with Mary, a Native American woman, who has a long history of trauma (both interpersonal and generational), and grief and loss. As well, Mary concedes that she has "lost her way" suggesting she has become distant from her traditional beliefs. She further said she wants to reconnect with her traditional beliefs. Paige, who considers herself culturally sensitive, has utilized a great deal of culturally appropriate techniques tailored to meet Mary's needs; however, Mary often alludes to her traditional spiritual beliefs and Paige is unsure how Mary's traditional spiritual beliefs should be incorporated into therapy. Through consultation and supervision, Paige decides to introduce the spiritual genogram to help Mary not only connect with the historical components of her cultural beliefs but to also help Paige determine how best to proceed in therapy. How would you describe the spiritual journey of your family? Your extended family? Your ancestors? What role have they played in your spiritual walk? How was your family's spiritual legacy affected over the generations? Are you aware of historical events that may have impacted your cultural and spiritual beliefs? What spiritually significant events have occurred in your family? How did your spiritual ways survive historical trauma (e.g., during the years of boarding school, relocation, and forced assimilation)? How did other members react to these challenges? How meaningful was their (family and kin) relationship with their spiritual life? Where did they find solace and peace (e.g., sacred site)? To what extent were their personal beliefs and their spiritual life similar? How did they express their spiritual beliefs to what extent did they enjoy talking with others about their spiritual journey? Enjoy their spiritual lives? How was spirituality a strength in their lives? How did their spirituality help them overcome the challenges they encountered in life? How did their cultural values and beliefs help them cope with these challenges? What are the differences, and similarities, among various family members in their spiritual beliefs and practices? Who was the spiritual leader in your family? What spiritual relationships stand out to you in your childhood years? What types of spiritually-based practices occurred at home (e.g., prayers, singing, ceremonies, etc.)? Who did you feel closest to while growing up (in a spiritual sense)? • • • • • • How do you define family? Who is in your family? How are family relationships described? In relationship to your family, what are your current spiritual beliefs? How have your beliefs (practices/feelings) changed since you were younger? How has your family's beliefs and practices affected your present expression of spirituality? How has the Creator worked through your family to touch you? How do you teach your children or young relatives [How were you taught] about learning their spiritual ways? What does this mean to your family, extended family, and traditional spiritual legacy? What have you learned about watching the elders and how they face life challenges? To what extent do you experience conflict and/or harmony with other family members over your spiritual beliefs? What have you accepted and rejected from your family's spiritual history? What prompted these decisions? How does your spirituality assist you in dealing with challenges? Are there ceremonies or spiritual practices that help you deal with these challenges? Does the severity of your struggle(s) usually decrease when you engage in certain spiritual practices? What spiritual strengths in your family's history could you draw upon to help you deal with challenges? What methods of dealing with challenges might you be able to adapt from others? What sort of insights could you draw from your spiritual genogram that might help strengthen you on your spiritual journey? (Limb & Hodge, 2009, p.244) Present spiritual functioning • • • • • • Historical components Culturally Sensitive Spiritual Genogram Questions for Native Americans Table 4.6 94 95 Over the next few sessions Paige introduced spiritual genograms and assisted Mary in developing her own. This exercise began to flourish during the initial session. Paige learned, for example, that Mary use to practice culturally traditional spirituality but was forced to discontinue spiritual practice when she was place in residential school. Over the years Mary neither reconnected with her cultural beliefs nor considered the impact her experiences were having on her and her family. As Mary completed her spiritual genogram she not only learned about the positive and negative influences on her spirituality but also reconnected with family members through prolonged discussions regarding her family ' s traditional cultural beliefs and ceremonies. Through this assessment procedure Paige was able gain a more complete understanding of Mary's historical and current spirituality. More importantly, this technique helped Mary begin to process the generational trauma she and her family experienced and the difficult task of dealing with her grief and loss. Equally important, Mary was able to reconnect with her traditional spiritual beliefs. She reports increased participation in ceremonial activities, seeking out Elder's teachings/guidance, reconnecting with nature, becoming more connected with family, reestablishing connection/relationship with Great Spirit/Creator, and reports greater self-awareness and self-acceptance. Recently, Mary reported to Paige that despite her grievous past she is finding peace and serenity (interconnectedness and balance) by reconnecting with her traditional cultural beliefs; she is also now assisting other family members along their spiritual journey. In this illustration Paige may have been less effective if she solely focused on secular counselling techniques. Like Mary's case, there are layers to individual's presenting problems, 96 and considering religion and spirituality are one of those important layers to uncover and explore. Consider exploring Figure 4.2 as it illustrates Mary's spiritual genogram; also consider the following questions: In what ways could Paige further help Mary with her spiritual journey? Are there other relevant assessment procedures and spiritual interventions that could be utilized? If you are presented with a client with similar issues how might you approach the subject of religion and spirituality? As the spiritual genogram is completed, counsellors can further help clients process the exercise by asking questions such as, "How has constructing a spiritual genogram provided insight into your current problem?" and "What have you learned about yourself and your familyof-origin through this process?" Ideally, the goal of constructing the spiritual genogram is for counsellors to enable clients to make important connections between past family beliefs, practices and experiences and how these connections are contributing to one's current condition. The spiritual genogram enhances the standard genogram as it provides specific information relative to religion and spirituality; as such, spiritual genograms are not only valuable for assessment information but can also be used as a therapeutic intervention as in the case of Mary. Assessing formative influences. In much the same way that the spiritual genogram is used to gather detailed information about client's religious and spiritual history and to assess one's current level of religious/spiritual influences, considering formative influences can also be very useful during the assessment process. This assessment technique may be more appropriate early on in the assessment process as the spiritual genogram typically produces broader, more in depth information. ( J Elsie 1931 After running away from residential school he never connected with any religious or spiritual beliefs f~ Attended residential school maintained First Nations' traditional he ;f\ M. 1925 Joined the First Nations Church Pizano 19271997 ~ Attended residential schooV as a mature adult returned to traditional beliefs Escaped from missionaries later became Medicine Man Anthony 19031976 Figure 4.2 Mary's Spiritual Genagram ~ Willie 18991965 No religion or spiritual beliefs I J Well know and respected Elder Attended residential school. Through counselling reconnecting to traditional beliefs ;f\ Charlie 1952 Used many traditional spiritual practices in life Mary 19021981 Tania 1972 M. 1949 Fought in WWII i Pierre 19251945 y l May 1973 t Shona 1976 Charlie 19292005 Agnostic Common-law 1972 Attended residential school t ')()()() Shona 1926- M. 1922 l L Sebastian 1951-2009 Raised Catholic rMhnlir Traditional Native American Spirituality Raised Catholic but never attended cPhnnl Refused to be Catholic but forced to attend residential t_ Bethia 1932 Placed in residential school became ~ Florence 19011989 97 98 Many clients' beliefs and assumptions do not actively come into play day to day. Instead, the interaction is more complex consisting of the things one has internalized and experienced to understand how religion and spirituality are currently being played out in ones life. Lines (2006) recommends that clients be given specific questions to help them become more aware of their formative influences. To help counsellors and clients to this end, he developed a table that can be utilized by counsellors for this assessment (see Table 4. 7). This exercise, he suggests, encourages clients to reflect and examine the primary influences and beliefs of their childhood and development. After answering the questions, clients are encouraged to consider how the questions they indicated influence and have contributed to their life. Quantitative Assessment Indexes and Scales There are an ever increasing number of quantitative religious and spiritual assessment instruments available to aid counsellors in assessing client's historical and current religious and spiritual influences and beliefs. These measures can be used within a comprehensive assessment or as stand alone assessment measures. Although spiritual assessment indexes can measure a variety of different domains, this section will focus on measures that specifically consider beliefs, values and experiences. The spirituality scale. Developed by Jagers, Boykin and Smith, the Spirituality Scale (SS) was first developed to assess spirituality from an Afro-cultural perspective (Jagers & Smith, 1996). Based on the definition that spirituality permeates life and transcends death connecting individuals with ancestors, this scale utilizes questions based on this definition on a 6-point Likert scale (Harper & Gill, 2005; Stanard et al, 2000). This measure is a holistic instrument that consists of23-items that are intended to measure the beliefs, perceptions, experiences, practices, and rituals illustrative of a client's spirituality; this scale is further designed to guide 99 Table 4.7 Assessing Formative Religious and Spiritual influences Response What I currently think Who/ What has influenced my to think this way ---r-:::: 0 Do I believe in God? Was I brought up in a religious household? t "' >< I.. ] ~