61611 • Integrating Religion and Spirituality into Counseling

Table of Contents

61611 • Integrating Religion and Spirituality into Counseling

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. MULTICULTURAL ISSUES IN THE PROVISION OF MENTAL HEALTH SERVICES

3. INCREASING DEMAND FOR MENTAL HEALTH SERVICES

4. ETHICAL SUPPORT FOR INTEGRATING SPIRITUALITY AND RELIGION INTO COUNSELING

5. ASERVIC: HISTORY AND COMPETENCIES

BACKGROUND

THE SPIRITUAL COMPETENCIES

CULTURE AND WORLDVIEW

SIMILARITIES AND DIFFERENCES BETWEEN SPIRITUALITY AND RELIGION

POSITIVE AND NEGATIVE ASPECTS OF SPIRITUALITY AND RELIGION

MAJOR WORLD RELIGIONS

6. COUNSELOR SELF-AWARENESS

EVALUATING THE INFLUENCE OF ONE'S SPIRITUAL AND/OR RELIGIOUS BELIEFS AND VALUES ON THE CLIENT AND THE COUNSELING PROCESS

RECOGNIZING LIMITS

7. HUMAN AND SPIRITUAL DEVELOPMENT

ALLPORT'S MODEL

FOWLER'S STAGES OF FAITH

OSER'S RELIGIOUS JUDGMENT MODEL

GENIA'S FIVE-STAGE FAITH DEVELOPMENT MODEL

WASHBURN'S THEORY OF PSYCHOSPIRITUAL DEVELOPMENT

LIMITATIONS OF MODELS OF RELIGIOUS/SPIRITUAL DEVELOPMENTAL

8. COMMUNICATION

9. ASSESSMENT

10. DIAGNOSIS AND TREATMENT

11. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

61611 • Integrating Religion and Spirituality into Counseling

Katherine Greig, MSW, PhD

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

There is a growing recognition of the importance of the spiritual domain in the counseling process and the need for training materials and strategies for integrating the Association of Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) competencies into the field of counseling. Although many counselors and educators endorse the spiritual competencies, there is little evidence that these competencies are being systematically and comprehensively addressed in counselors' training. This course summarizes the revised ASERVIC competencies, their relevance, and application in the counseling process, explaining why it is important for counselors to be proficient in each area before working with spiritual and religious issues in counseling. These competencies will enable counselors, social workers, mental health professionals, and allied professionals to develop a framework to assist them in understanding and working effectively with clients' spiritual and religious lives.

61611 • Integrating Religion and Spirituality into Counseling

Education Category. Community Health

Release Date. 06/01/2023

Expiration Date. 05/31/2026

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/2634 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

There is a growing recognition of the importance of the spiritual domain in the counseling process and the need for training materials and strategies for integrating the Association of Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) competencies into the field of counseling. Although many counselors and educators endorse the spiritual competencies, there is little evidence that these competencies are being systematically and comprehensively addressed in counselors' training. This course summarizes the revised ASERVIC competencies, their relevance, and application in the counseling process, explaining why it is important for counselors to be proficient in each area before working with spiritual and religious issues in counseling. These competencies will enable counselors, social workers, mental health professionals, and allied professionals to develop a framework to assist them in understanding and working effectively with clients' spiritual and religious lives.

Audience

This introductory course is designed for psychologists who work in clinical practice settings.

Accreditations & Approvals

Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is recognized by the New York State Education Department's State Board for Psychology as an approved provider of continuing education for licensed psychologists #PSY-0240. This course is considered self-study by the New York State Board for Psychology.

Designations of Credit

NetCE designates this continuing education activity for 5 credit(s).

Course Objective

The purpose of this course is to assist psychologists in raising their level of expertise when working with clients who present with spiritual and religious issues.

Learning Objectives

Upon completion of this course, you should be able to:

1. Explain the relationship between clients' spiritual/religious beliefs, worldviews, and psychosocial functioning.

2. Outline the history and current role of the incorporation of spirituality and religion in counseling.

3. Describe the similarities and differences between spirituality and religion, including the basic beliefs of various spiritual systems and major world religions.

4. Discuss the influence of the counselor's beliefs, attitudes, and values on clients and the counseling process.

5. Describe and apply various models of spiritual and religious development and their relationship to human development.

6. Respond to client communication about spirituality and/or religion with acceptance and sensitivity.

7. Consider clients' spiritual and/or religious perspectives when gathering information for the intake and assessment processes.

8. Recognize when making a diagnosis that clients' spiritual and/or religious perspectives can enhance well-being, contribute to client problems; and exacerbate symptoms.

9. Set goals with clients that are consistent with their spiritual and/or religious perspectives.

Faculty

Katherine Greig, MSW, PhD, is the CEO of New Perspective Counseling Center LLC in Cleveland, Ohio. She is a trainer, consultant, and retired professor of social work. She received her Bachelor of Arts in Education and a Master’s in Counseling Education from Cleveland State University. Later, she received a Master’s in Social Work and a PhD in Social Administration from Mandel School of Applied Social Sciences at Case Western Reserve University.

Dr. Greig has worked in the fields of social work and counseling for more than 30 years. Her specialty areas include depression, anxiety, relationship issues, and Christian counseling. Dr. Greig is a certified Critical Incident Stress Management (CISM) consultant, Substance Abuse Professional (SAP), and Employee Assistance Program (EAP) specialist.

Faculty Disclosure

Contributing faculty, Katherine Greig, MSW, PhD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Margaret Donohue, PhD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Over the past few decades, the number of books and journal articles on the role of religion and spirituality in the field of counseling and psychotherapy has increased significantly. At the same time, mental and behavioral health professionals have become more aware of the importance of the spiritual domain in the field of counseling. This renewed interest in the spiritual domain is an indication that something is missing when spirituality is not included in health and wellness models [1,2]. When the spiritual dimension is not incorporated into care, the whole person is not being addressed—the component that has to do with giving life meaning and purpose and connecting to self, others, life, nature, and/or a Higher Power/Ultimate/God is missing [1,2,3,4,5,6]. Moreover, one could be overlooking the heart of what it means to be human, because spirituality is a vital component of being human [3].

Diverse theories emphasize the importance of the holistic approach to wellness, and concepts related to holistic wellness continue to inform best practices for counselors, social workers, and other mental health professionals [7]. Accordingly, the counseling wellness model includes a commitment to promoting holistic health throughout the entire lifespan; the spiritual domain is considered an important factor in this model. The holistic perspective recognizes human multidimensionality and therefore takes into account the physical, mental, emotional, and spiritual dimensions of clients when they present for treatment. As a result, the individual is perceived as a unified whole. Of the various dimensions, the spiritual dimension may have the greatest impact on overall personal health [8].

Research has supported relationships between spirituality and physical and mental health [5,9,10,11,12,13,14,15]. In particular, spirituality/religion has been found to have a positive effect on positive coping, resilience, psychosocial competence, self-esteem, and recovery from severe mental disorders [16,17,18,19,20]. Likewise, religious engagement is correlated with decreased perception of pain and reduced incidences of suicidal ideation and substance abuse [1,21,22].

Although there are numerous studies on the positive impact of spirituality and/or religion on physical health, the impact of spirituality and/or religion on mental health has been more widely studied [10]. Mental disorder is the main cause of disability in the United States, and it affects all areas of life, including finances, work and leisure, daily functioning, relationships, self-esteem, and spiritual functioning [23]. As of 2021, there were approximately 57.8 million adults with mental illness, including 19.4 million adults with co-occurring substance use and mental illness, and 7.7 million youth between 6 and 17 years of age with mental health disorders [24].

Moreover, mental disorder is considered the costliest medical condition in this country [25]. It is estimated that the costs for mental health services were approximately $280 billion in 2020 [25]. Both the pervasiveness of mental illness and the cost of treatment have made this one of the main contributors to rising healthcare costs [23,25]. As such, prevention and treatment of mental illnesses would reduce the financial burden on the healthcare system while also improving community health. In this regard, the spiritual domain may be a valuable resource for professionals working with persons with mental disorders [23].

Although counselors and mental health professionals agree about the need to integrate the spiritual domain into the counseling process, there is less agreement as to how this may be best done [26,27]. Educators have explored strategies for fusing the spiritual domain into the curriculum of education programs, which may be the best option to train students regarding the Association of Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) competencies [28,29,30]. However, continuing education activities are also helpful [23].

The purpose of this course is to increase mental and behavioral health professionals' knowledge and skills when addressing spiritual and religious issues in counseling. To this end, the course will discuss why spirituality and/or religion should be integrated into the counseling process; the origin of ASERVIC; the ASERVIC competencies and their relevance; and why it is important to be proficient in each of the competencies prior to working with the spiritual domain in the counseling process.

2. MULTICULTURAL ISSUES IN THE PROVISION OF MENTAL HEALTH SERVICES

As noted, counseling has become more multiculturally aware in past decades due to the multicultural movement and its attention to issues of diversity [31]. The movement began in the early 1960s in response to a recognition that the United States had become increasingly diverse in race, culture, and language [31]. Racial segregation and discriminatory practices were widespread, which led to the Civil Rights Act of 1964 [31]. The movement had a significant impact on the counseling profession, because it changed the way counselors related to their clients [23].

The 1980s witnessed the development of the Multicultural Counseling Competencies (MCC). The primary focus of the MCC was to provide guidance to counselors working with racially and ethnically diverse clients [23,32]. In 1991, the MCC was approved by the Association for Multicultural Counseling and Development (AMCD) as standards for counselors' training and practice [33]. Initially, the MCC focused primarily on racial and ethnic aspects of diversity; religion, spirituality, and other aspects of diversity were added later, and the MCC was updated to be the Multicultural and Social Justice Counseling Competences (MSJCC). However, spirituality and religion, along with other aspects of diversity, continue to be under-represented in the MCC, raising doubt as to whether a multiculturally competent counselor is necessarily spiritually competent [23,27]. The MSJCC, ASERVIC, the American Counseling Association (ACA), and the Society for Sexual, Affectional, Intersex, and Gender Expansive Identities (SAIGE) work closely to provide inclusive competencies for mental health counseling theories, practices, and research [105].

Immigration to the United States was at an all-time high during the last half of the 20th century [34]. In 2021, immigrants comprised approximately 13.6% of the U.S. population, and this percentage has been steadily increasing [36]. Consequently, the cultural landscape of the United States is becoming even more diverse [35]. Hispanics and Asians have the highest growth in population when compared with Black/African Americans, Native Americans, and White/European Americans [36]. Unlike previous generations, immigrants have higher education, greater financial resources, are primarily employed in management, business, science, and arts occupations, and do not find it necessary to assimilate fully into the dominant culture [23,33,36,37]. Accordingly, new immigrants are more likely to maintain their cultural traditions and heritage, which include their spiritual and religious traditions [23,27].

3. INCREASING DEMAND FOR MENTAL HEALTH SERVICES

It is well documented that when individuals face psychological distress they are likely to turn to existing religious resources (e.g., prayer, faith, trusting in God's will, the clergy) to cope [5]. As such, many individuals seeking counseling services want their spiritual beliefs included in their counseling experience [27,38,39]. In a study of 655 individuals diagnosed with a mental illness, 65% stated they wanted to talk about spiritual issues with their therapist, whereas 35% said they did not feel comfortable doing so [40].

Individuals consistently identify spiritual and/or religious needs as important issues in their lives [20,22,41]. Clients and counselors agree that religion and/or spirituality should be included in counseling and are open to discussing such issues [42,43,44,45,46]. However, many mental and behavioral health professionals have not received the necessary training to do so appropriately, effectively, and confidently.

According to a Pew Research Center survey, approximately 90% of Americans believe in some kind of higher power [41]. Around 56% believe in God as described in the Christian Bible, and 33% said they believe in another type of higher power or spiritual force. Roughly 11% said they do not believe in God or a higher power of any kind. Based on these findings, it is safe to assume that spiritual and/or religious issues are important to many individuals seeking counseling services. Neglecting these aspects of diversity in counseling or therapy denotes a failure to respect the individual as a whole and could be viewed as an ethical violation [47].

4. ETHICAL SUPPORT FOR INTEGRATING SPIRITUALITY AND RELIGION INTO COUNSELING

Based on studies validating the positive correlation between religion and health, professional organizations have increased their efforts to infuse spirituality and religion into counseling, training and practice [6,10]. Both the American Psychological Association (APA) and the ACA have formally acknowledged religion in their ethical guidelines as an issue for counselors to consider in their practice [48,49]. Additionally, the APA has authorized a division (36 Society for the Psychology of Religion and Spirituality) specifically for the study of the psychology of spirituality and religion [10].

The Council for Accreditation of Counseling and Related Educational Programs (CACREP) requires the inclusion of spirituality and religion issues in counselor education programs [50]. The Joint Commission asserts that spiritual services are important aspects of health care and daily life [51]. In 2001, the Joint Commission revised its standards and now mandates a spiritual assessment for patients; these standards continue to be reviewed to ensure a thorough spiritual assessment. Such recognition validates the importance of spiritual care for clients seeking health services [11,51,52].

5. ASERVIC: HISTORY AND COMPETENCIES

ASERVIC was established in 1951 through the merging of three Catholic counseling organizations [27]. It is currently a division of the American Counseling Association and consists of counselors who believe spiritual, ethical, and religious values are essential to the overall development of a person [6]. Its primary mission is the integration of spiritual, ethical, and religious values into the counseling profession. Accordingly, ASERVIC plays a central role in the incorporation of spirituality and religion into counseling practice and counselor education programs [52].

BACKGROUND

The first Summit on Spirituality was a major event in ASERVIC's history. For this Summit, a group of experts in spirituality and counseling convened in the fall of 1995 in order to discuss how the organization could guide the profession toward spiritual competency [27]. It became evident that the construct of "spirituality" presented a challenge to define, and a review of the literature confirmed this struggle [53]. Therefore, ASERVIC's leadership commissioned a task force to develop a description of spirituality and a set of competencies that would support counselors in serving clients from various religious and spiritual traditions [27,53].

Outcome of Summit I

After a series of town hall meetings at professional conferences over several years, the Summit group developed a description of spirituality and a set of competencies [27,53]. The development of counselors' competencies gave structure to the discussion that had been taking place and provided data to be included in curricula and accreditation standards. The summit initially produced 23 competencies, which later became 10 guidelines and finally resulted in 9 items. ASERVIC endorsed the 9 items in 1996, and these items have also been endorsed by the ACA Governing Council [27,54].

Outcome of Summit II

Summit II convened in the summer of 2008 with various leaders and scholars in spirituality and counseling. The primary focus of this summit was the revision of the competencies developed at the previous summit. The counseling profession strongly endorsed the spiritual competencies, and it was recommended that the competencies be used to inform curriculum development [27]. In spite of the effort that went into the development of the competencies, spiritual and religious material continues to be neglected in counselor training programs.

Counselor educators supported the inclusion of the revised competencies in curricula. However, it was not clear whether educator training was needed or if training would accomplish outcome measures of increased knowledge, skills, and attitudes needed to assist clients with their spiritual and religious concerns [27]. It became apparent that a formal measurement tool was needed, and the Spiritual Competency Scale (SCS) was developed to meet this need [23]. A pilot study of the SCS was conducted with 602 participants, and the findings supported the use of the SCS to "inform curriculum development, as a measure of training outcomes, and as a tool for the certification of spiritually competent counselors" [23].

THE SPIRITUAL COMPETENCIES

The ASERVIC competencies continue to serve as a guideline for addressing spiritual and religious issues in counseling and are intended to be used with traditional counseling techniques that are evidence-based and coincide with best practices. The 14 competencies are grouped under six primary categories [6]:

- Culture and worldview

- Counselor self-awareness

- Human and spiritual development

- Communication

- Assessment

- Diagnosis and treatment

CULTURE AND WORLDVIEW

At the beginning of each section, the ASERVIC competencies for the category will be listed.

Competency 1

The professional counselor can describe similarities and differences between spirituality and religion, including the basic beliefs of various spiritual systems, major world religions, agnosticism, and atheism.

Competency 2

The professional counselor recognizes that the client's beliefs (or absence of beliefs) about spirituality and/or religion are central to his or her worldview and can influence psychosocial function.

SIMILARITIES AND DIFFERENCES BETWEEN SPIRITUALITY AND RELIGION

The word spirituality is derived from the Latin root spiritus, which means breath of life [1,55]. Due to the elusive nature of the concept of spirituality, leaders attending the first Summit on Spirituality found it difficult to define. Instead, they chose to describe it as [6]:

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 precedes and transcends culture.

The word religion is derived from the Latin word religio, which means a bond between humanity and greater-than-human power [56]. Many people use the terms religion and spirituality interchangeably; however, they are two separate concepts that often overlap [10,39,57]. Spirituality is a personal connection with the universe, whereas religion is an organized community of faith that has a written doctrine and codes that regulate behavior [14]. Although they are two separate concepts, both incorporate a sense of transcendence—a belief in something greater than oneself [58].

As noted, there has been much discussion and confusion regarding the definition of religion and spirituality, and the majority of people (74% and 88%) do not distinguish between the two [27]. However, it is important to understand that there is a continuum of religiousness and spirituality, and it is essential to recognize where each client falls on this continuum. Clients will present for counseling services with different perspectives regarding religion, spirituality, and the relationship between the two concepts [27]. For example, some clients will say they are religious but not spiritual. These individuals go through the motions of following the practices of the group. They do so out of a sense of duty or obligation, or they fear the consequences of not participating from family members or punishment from God [27]. There are clients who say they are spiritual and not religious. These individuals are not affiliated with a particular religion or belief system but still feel connected to something greater than themselves. They are primarily concerned with their own personal spiritual journey. The number of individuals in this category is growing [27]. Clients can be both religious and spiritual. To these individuals, religion and spirituality are intertwined and they strengthen each other [27]. There are also clients who are religiously tolerant and indifferent. These persons are tolerant of others' religion but are not committed to organized religion [27]. Lastly, there are clients who are religiously antagonistic. These individuals often consider themselves spiritual but have negative feelings toward organized religion. Usually, these individuals have had negative experiences with organized religion or grew up in families that were prejudiced toward organized religion [27]. Regardless of where clients happen to fall on the continuum, it is important to understand each client's perspective, as well as each client's readiness and willingness to discuss his or her spiritual/religious beliefs, or lack thereof [27].

POSITIVE AND NEGATIVE ASPECTS OF SPIRITUALITY AND RELIGION

Like any intervention, spirituality and religion have beneficial as well as adverse effects [5,10,21]. According to Jones and colleagues, one's spiritual or religious beliefs have a significant impact on physical and mental health outcomes [21]. Negative spiritual beliefs are related to poorer health outcomes, whereas positive spiritual beliefs are related to better health outcomes. It is estimated that 10% of the population has negative spiritual beliefs [21].

A study of 200 individuals was conducted to determine how their spiritual beliefs impacted their health outcomes [21]. Individuals in the study had a range of health conditions, including traumatic brain injury, chronic pain, and cancer. Individuals who held negative spiritual beliefs (e.g., feeling punished or abandoned by God) had poorer physical and mental health outcomes and an increased perception of pain. Individuals who held positive spiritual beliefs (e.g., feeling loved and forgiven by God) had better health outcomes and a decreased perception of pain.

Other examples of negative spiritual beliefs include [59,60]:

- God is not supportive.

- One should rely on faith alone for healing.

- Crises are punishment from God.

- Turning to medicine shows a lack of faith.

- Lifesaving medical treatment should be refused for self and family members.

Negative spiritual and religious beliefs can impair health and well-being because they create a toxic environment, lowering immune system functioning and increasing both stress hormones and blood pressure [21]. Additionally, negative spiritual beliefs diminish hope and optimism, potentially increasing mental health problems such as depression and anxiety. In short, positive or healthy spiritual beliefs may enhance well-being, while negative or unhealthy spiritual beliefs contribute to the problem by diminishing hope and instilling fear, which may exacerbate symptoms.

MAJOR WORLD RELIGIONS

The following section provides a brief overview of the beliefs and practices of the major Western and Eastern religions. It is hoped that counselors and mental health professionals will gain an understanding and appreciation of diverse religious and spiritual beliefs and practices. As a result, counselors and mental health professionals will be better prepared to meet clients' needs and enhance their well-being. This overview is meant only to give a simple, brief summary of the general ideology of each religion. By no means are all of the rites or beliefs described practiced by all members of each religion; likewise, not all religious rites or beliefs are discussed for each religion. As always, individualized assessment is encouraged.

Before discussing the various religious and spiritual beliefs and practices, it is important to have an understanding of the concept of "worldview" [61]. Worldview refers to one's total outlook on life. Clients' worldviews are shaped by their culture, religion and/or spirituality, race, ethnicity, sociopolitical factors, age, ability, sexuality, gender expression, family, and other variables. These variables interact to form clients' total worldviews, which influence the way they think, feel, and behave [14,15,27]. Wiggins-Frame writes that, "counselors must be aware that our clients bring to us not only their problems and their pain but also their views of the world molded by culture, religion, and the intersection of the two" [53].

The three major Western religions are Judaism, Christianity, and Islam. All three are monotheistic, meaning their followers believe in one Supreme Being or God who created and sustains the universe. The major Eastern religions include Hinduism, Buddhism, Confucianism, Taoism, and Shintoism. These religions are typically polytheistic (worshiping more than one God) or pantheistic (God is manifested in the forces and laws of the universe). A separate group of religions may be described as atheistic or agnostic [15]. Atheism is the disbelief in the existence of a god or gods; agnosticism holds that the existence of God is unknown and unknowable [27,53,62].

Western Religions

Judaism

Judaism emerged in the Southern Levant (an area in the Middle East) in about 2000 B.C.E. [63]. The word Jew is derived from the term yehudah, or Judah, the Southern Kingdom of Israel that existed from 922 to 586 B.C.E. [64]. There are approximately 13 million Jewish people in the world—6 million in North America, 4.3 million in Asia, and 2.5 million in Europe [62]. Jewish descent is traced through the maternal line, but the choice to practice Judaism is made by the individual. Persons who are not born to Jewish mothers may convert to Judaism through a procedure specific to the sponsoring denomination [64]. In Jewish tradition, the Torah is believed to be the word of God and the ultimate authority.

There are three tenets of Judaism. The first tenet is monotheism; there is one God who created the universe and continues to rule. In Jewish tradition, the name of God is revealed to Moses as the Hebrew consonants yhwh. This is often stylized as Yahweh, but Jewish individuals traditionally do not pronounce it. Yahweh is described as "eternal, omniscient, omnipotent, and holy" [53]. The second tenet is that the Jews were chosen to receive the law of Yahweh and to serve as role models for humankind [53]. The third tenet refers to the covenant, which is a contractual agreement between God and the Jews. According to the agreement, they will be rewarded if they obey God and keep his commandments; failing to do so would result in divine retribution. Also, they believe that studying the Torah and faithfulness to God and his commandments may hasten the arrival of the Messiah [27,53].

Jewish law focuses on dietary practices, the Sabbath, and annual holidays or festivals. Observing the dietary laws is called keeping kosher. One's home is considered the table of the Lord, and therefore certain animals considered unclean (e.g., pork, shellfish) are not to be eaten. However, animals with split hooves and animals that chew their cud are acceptable. Acceptable animals must be slaughtered correctly, must have the blood drained from them, and must not be served with dairy products. Those who adhere to kosher laws have separate sets of dishes and utensils for preparing and serving meat, dairy products, and Passover meals [53,65].

Sabbath is a day of rest and rejuvenation. Observance of the Sabbath usually takes place on Saturdays. Passover, Hanukkah, Rosh Hashanah, and Yom Kippur are major festivals observed by members of the faith. Passover is the festival celebrating the exodus from Egypt and liberation from bondage. Hanukkah celebrates the triumph of the Maccabees over the Syrian King Antiochus IV in 165 B.C.E. [27,53]. Rosh Hashanah marks the beginning of the two-day celebration of the Jewish New Year. Yom Kippur, also known as the Day of Atonement, is the holiest day of the year in Judaism and occurs eight days after Rosh Hashanah. Its central themes are atonement and repentance.

Christianity

Christianity emerged in the 1st century C.E. It is the largest religion in North America, and there are approximately 2 billion followers worldwide [27]. There are three major divisions in Christianity: Roman Catholicism, Eastern Orthodoxy, and Protestantism [27,53]. Christianity is based on the life and teachings of Jesus Christ, a Jew who was born in Bethlehem (in modern-day Palestine) and is believed by Christians to be God's promised Messiah. In Hebrew, Jesus means "God saves" and Christ means "Messiah" [62]. Accordingly, they believe that salvation and eternal life can be obtained through their belief in Jesus [62]. Most Christians believe Jesus was crucified and later resurrected by God and that he continues to live and reign with God. At the end of time, Christians believe Jesus will return to earth and establish his Kingdom, which he began during his earthly existence [27].

Christians also believe Jesus is both human and divine or God in human form [65]. As an ongoing source of comfort and guidance, God offered them the Holy Spirit [65,66]. Christians believe God's grace is a gift and that it saves them from evil, sin, and death. Moreover, grace is earned not by doing good deeds or obedience to the law, but through living by the teachings of Jesus Christ [27,65]. The concept of the Trinity is also basic to Christian belief. Although God is perceived as one, God is also expressed in three roles: Father (Creator), Son (Redeemer), and the Holy Spirit (Sustainer) [53,65].

Baptism and the Eucharist or Holy Communion are the primary sacraments celebrated in most Christian churches [53]. Baptism symbolizes the forgiveness of sins, new life, and initiation into the Christian church. During the baptism, persons are either immersed in water or water is sprinkled or poured over them. Eucharist or Holy Communion is a ritual meal in which bread and wine are taken in remembrance of the body and blood of Jesus that was broken and shed at the cross [27]. Major Christian holidays include Easter (commemorating the death and resurrection of Jesus Christ) and Christmas (celebrating the birth of Jesus).

Christians consider the Bible to be the word of God. It is composed of 66 to 81 separate books (depending on denomination). The Bible is comprised of the Hebrew scriptures (Old Testament) and the New Testament, which consists of the four gospels (Matthew, Mark, Luke, and John), Acts, the letters of the apostle Paul, and Revelation [53]. Christians hold various perspectives on the nature, purpose, and approaches to the interpretation of the Bible.

Islam

Islam is the fastest-growing religion in the United States and throughout the world [41]. Members of Islam are called Muslims, and approximately 3.45 million live in the United States [41]. Islam means "to surrender" in Arabic. However, from a religious perspective, Islam means "to surrender to the will of God" [67]. Islam began in Arabia around 570–632 C.E. and was founded by the prophet Muhammad. It is a monotheistic religion whose followers believe there is one God and that Muhammad was his last Prophet. They believe the Qur'an (or Koran) is the literal word of God (or Allah in Arabic) that was revealed to Muhammad and mediated by Gabriel, the angel of revelation [67]. Arabic is the language used in Islamic prayer/liturgy [62]. Major festivals or holidays include Al-Hijra, Milad un Nabi, Ramadan, Eid al-Fitr, Eid al-Adha, Day of Ashura, and Laylatul Qadr.

Most Muslims are of one of two denominations: Sunni and Shia. While various denominations may have slightly different beliefs or translations, Islam has six major doctrines. The first is the belief in divine unity, or tawhid [27,53]. The second is the belief in angels as agents of God. Angels have many functions, such as carrying messages to prophets and watching over and keeping track of people. The third is a belief in prophecy as revealed in the Qur'an. The fourth involves belief in scripture (Qur'an), and the fifth is the belief in Judgment Day and life after death [27,53]. On the Last Day (or final judgment), both the living and the dead will be judged. The faithful will be rewarded, and the unfaithful will be cast into hell. Finally, the sixth doctrine is the Divine Decree and Predestination. It suggests that Allah has already determined who will receive eternal salvation [27,53].

The Five Pillars are the core beliefs and practices of Islam. The first is the Shahada (profession of faith)—the belief that there is no god but Allah and Muhammad is his messenger [27]. The second pillar is the Salat (ritual prayer). Muslims pray facing Mecca five times every day: at dawn, noon, mid-afternoon, sunset, and evening [53]. The prayers are usually performed on a rug or mat specifically for this purpose. Zakat (almsgiving) is the third pillar of Islam. Muslims are expected to donate a certain portion of their income to community members in need [68]. Sawm (or fasting) is the fourth pillar of Islam. During the daylight hours of Ramadan, healthy adult Muslims are expected to abstain from food, drink, and sexual relations. This is a time of reflecting, renewing faith, and being grateful for everything Allah has given [68]. The fifth pillar of Islam is Hajj (pilgrimage). After 16 years of age, every Muslim in good health and whose finances permit is expected to visit the holy city of Mecca, located in present-day Saudi Arabia.

Eastern Religions

Hinduism

Hinduism is one of the world's oldest religions, dating back to about 1500 B.C.E. [69]. Unlike other major religions, it was not founded by a single person but was born of many religious beliefs and philosophies [70]. Hinduism originated in India, and today it is the third-largest religion in the world. There are approximately 1.1 billion adherents worldwide and 2.3 million adherents in the United States [71]. Hinduism is a polytheistic religion with three major deities: Shiva, Vishnu, and Brahma [69].

Hindus believe there are four paths, or yogas, leading to a spiritual life and that each person must choose the path that best fits his or her temperament. One path is Jnana Yoga, which appeals to intellects who travel the path of knowledge. Another path is Bhakti Yoga, which is the path of love and devotion as a way to god. Individuals on this path utilize mantras as a means of altering one's consciousness. Another path is Karma Yoga, which is the path of performing daily activities or work instead of contemplation. Finally, the path of Raja Yoga is the path of psychological experimentation and meditation as a way to one's true nature [72].

In addition to the four paths toward God, there are four stages (or ashramas) in life leading to moksha or liberation. The stages involve duties boys/men have throughout their lives. The first stage is the student stage (brahmachari). It involves the study of the religion under the guidance of a teacher. Grahasthin, the second stage, is referred to as the householder. It involves maintaining a home and family and giving alms to those who have reached a different karmic stage [70]. The third stage is called the forest dweller (vanaprasthin). It consists of elderly men who perform rituals honoring their ancestors. Finally, the fourth stage, referred to as sannyasin or renunciation, involves giving up the material world entirely to experience liberation [70].

Two concepts are central to Hinduism: karma and reincarnation. Karma refers to the spiritual principle of cause and effect. In short, people's circumstances are the result of present and past-life actions of good or evil [27]. Hindus also believe in the continuous cycle of life, death, and rebirth (reincarnation) that continues until the soul "transcends all pain and pleasure and release itself from all fears and attachments" [53]. This state is called samsara or transmigration [53].

The caste system is traditionally central to Hinduism as well. Historically, it divided people into four hierarchical categories [53]:

- Brahmans (seers)

- Kshatriyas (administrators)

- Vaishya (businesspersons)

- Shudra (laborers)

Later, a fifth category of untouchables emerged, and people in this category were subject to discriminatory practices [53]. This discrimination is now illegal in India. Marriage is typically expected to be within the caste (jati), and the hope is for male heirs [69].

The Hindu temple is a cultural center where people come to sing, read sacred texts, and perform rituals [27]. The chanting of mantra called pathas is a traditional Hindu practice and is believed to have transformative power. Puja or daily worship is an important aspect of Hinduism. It entails the offering of food, incense, flowers, fruits, ashes, and other articles to an image of a deity [72]. Tirthas refer to pilgrimage sites and holy places in Hinduism [72].

There are many sacred texts in Hinduism, including The Ramayana, an epic tale of Lord Rama's victory over the 10-headed demon Ravana, and The Mahabharata, the world's longest epic poem that is an historical account of the birth of Hinduism along with a code of ethics for the faithful [27]. Major Hindu festivals include Makar Sankranti, Holi, Diwali, Mahashivratri, Vasant Panchami, Rama Navami, and Janmashtami/Krishna Jayanti.

Buddhism

There are approximately 3 million Buddhists in the United States and about 488 million worldwide [71]. Buddhism was founded in northeastern India by Siddhartha Gautam, whose name was later changed to the Buddha or Enlightened One. Around the year 563 B.C.E., Buddha was born into a wealthy family as a prince in present-day Nepal. He was saddened by the suffering in the world and the emptiness of his life [73]. He later realized that he could be subjected to different forms of human suffering (e.g., death, disease) as well. Consequently, at 29 years of age, he left his home and became a wandering monk seeking a resolution to suffering and death.

He sought knowledge from several forest yogis and learned meditation techniques. He joined the five yogis and practiced extreme forms of asceticism and almost starved to death [73]. That is when he realized that neither extreme pleasure nor self-denial was the path to nirvana (release from suffering). After six years, Buddhists believe Gautama found enlightenment while meditating under a Bodhi tree and was released from the cycle of rebirths [73]. He began promoting the idea of a middle path that focused on purity of thought and deed. Buddha believed awareness was the path to overcoming death [104]. He did not want to be worshiped as a god or savior. Instead, he believed his role was to help people find their path to freedom and enlightenment.

The Four Noble Truths and the Eightfold Path are essential to understanding Buddhism. The Four Noble Truths have been identified as the first teaching given by Buddha. They are considered one of the most important teachings in Buddhism because they instruct followers on how to end suffering [27,62]. Within the Four Noble Truths is found the Eightfold Path. The Four Noble Truths are [62]:

- There is suffering in life.

- Human desire is the cause of suffering.

- The end of human suffering is possible.

- The Eightfold Path is how one achieves nirvana.

Collectively, the Four Noble Truths explain why humans suffer and how to overcome suffering. Wangu describes the Eightfold Path as consisting of the right opinion, right intentions, right speech, right conduct, right livelihood, right effort, right mindfulness, and right concentration [74]. These eight paths are grouped into three key elements of Buddhist practice: morality, wisdom, and concentration [73]. Buddha taught the Eightfold Path in all of his discourses. Buddha understood that everyone is not suited to be a monk, so his followers were given the Five Precepts to learn and practice. The Five Precepts or moral codes are to be undertaken by lay followers of Buddhism in order to develop mind and character, which leads to enlightenment [73].

The Five Precepts for everyday behavior are "to refrain from killing, from taking what is not mine, from sensual misconduct, from false speech, and from using intoxicating substances that cloud the mind" [74]. Similar to Hinduism, karma is a key component of Buddhism. Accordingly, good deeds are rewarded and evil deeds are punished. Karma is viewed as a universal law that "determines one's destiny—whether one is reborn as a human, animal, or some other creature, such as a god or the devil" [73].

Buddhists also engage in rituals such as chanting and placing flowers, candles, and incense before an image of Buddha. Flowers represent the impermanence of life, incense assists followers in remembering moral virtue, and fire denotes enlightenment [75]. Buddhists celebrate many holidays and festivals, most of which commemorate important events in the life of the Buddha. Every year, Buddhists celebrate Vesak, a festival that commemorates Buddha's birth, enlightenment, and death. During each quarter of the moon, followers of Buddhism participate in a ceremony called Uposatha [75]. This observance allows Buddhists to renew their commitment to their teachings. Buddhist New Year is a time for reflection of past lives and identifying and rectifying mistakes [27].

Confucianism

Confucianism is described as a way of life, philosophy, religion, or ethical code by which to live [53]. It was developed from the teachings of Confucius, who was born around 551 B.C.E. [76]. These teachings focus on good conduct, wisdom, and proper social relationships. Confucius has had a great influence on Chinese culture. Although temples were built to honor him, he is not perceived as a god. The temples are used for public ceremonies only and not as places of worship [77].

Confucianism advocates eight key concepts. The first is Jen, which translates as love, human-heartedness, and goodness [77]. Jen refers to "a feeling of humanity toward others and respect for oneself, an indivisible sense of the dignity of human life…" [76]. The second concept is Chun-tzu, which refers to a state of centeredness whereby one exhibits Confucians' values effortlessly and without the need for self-monitoring. The third concept is Li, or a sense of order in one's life that coincides with social convention. The fourth concept is Te, or the appropriate use of power by leaders and authority figures. Confucius believed leaders should lead by example and not by force. They should be honorable and benevolent, which will lead to people being respectful and obedient. The fifth concept is Wen, which refers to the cultural arts (e.g., music, drama, poetry) that help to maintain unity in society [76]. The remaining concepts are Chi (the wisdom of proper action), Hsin (integrity), and Yi (righteousness or justice).

Taoism

Taoism (pronounced DOW-ism) is a Chinese philosophy and religion dating back to the fourth century B.C.E. [27]. Tao means "the way," and it has no founder or central figures. Taoists do not worship a god. Instead, they focus on coming into harmony with Tao, the cosmic energy that blows through everything. Taoism emphasizes what is natural and going with the flow of life. Today, there are about 20 million Taoists, and most followers live in China, Taiwan, or Southeast Asia [27].

The word Tao has three different meanings. First, Tao refers to the ultimate reality; therefore, it is "unspeakable and transcendent, the ground of all existence" [53]. Second, Tao is the cycles of nature and constant change that are evidence of the universal force [78]. Third, Tao implies the way to peace is through synchronizing one's life with the natural rhythm of the universe [76]. Being in concert with Tao means doing nothing stressful, artificial, or unnatural. Taoists seek balance and harmony in life, particularly in their approach to diet and exercise. Meditation is an important practice, and the goal of meditation is to come into harmony with the universe [27]. The philosophy is found in a text, the Tao-te-Ching (Classic Way and Its Power), dating back to the third century B.C.E. and attributed to Lao Tzu [53].

Shintoism

Shintoism began during prehistoric times on the Japanese islands [79]. Today, Shinto is the religion of Japan, and it has approximately 112 million followers; more than 75% of them follow Buddhism as well [79]. Like Taoism, Shinto has no founder or central figure. It teaches that all things in the world are imbued with a spirit (kami). Therefore, Shinto followers revere nature in all forms [78].

Most of the deities associated with Shinto are related to nature, such as the sky, earth, heavenly bodies, and storms [80]. However, deities are not different from humans, because everything is imbued with spirit. Everything is connected, including rocks, trees, dust, water, animals, and humans [81]. Shinto focuses on "simplicity and cleanliness as signs of inner goodness" [53].

Shinto has no fixed doctrine and no scripture or sacred text. However, ancient prayers are passed down via oral tradition. Shinto followers worship primarily individually rather than in groups, and followers engage in purification rituals (e.g., handwashing) [79]. Worship occurs outside the shrine, and worshipers usually bring offerings of food or coins for the spirit (kami). These offerings are not given as sacrifices but as signs of gratitude [79]. Some followers write prayers on slips of paper and leave them nearby.

New Age Spirituality

The New Age movement became popular in Western society in the 1970s [82]. The precise definition of the term differs among scholars largely due to its highly eclectic range of spiritual beliefs and practices [82,83]. The movement takes many shapes and is continually changing. However, there are some common features that distinguish it from other religions, such as followers who [27]:

- Look forward to a society that reunites the wisdom of both science and religion

- Adopt holistic and alternative healing methods

- Embrace a wide array of traditional and nontraditional spiritual beliefs and practices

- Accept the existence of a universal energy that undergirds and permeates all of existence

Adherents believe healing can occur when individuals connect with this universal energy and learn to use it. This energy has been called by many names by different cultures, including chi (Chinese), ki (Japanese), prana (Sanskrit), mana (Pacific Islander), or the use of self as a final authority [27].

6. COUNSELOR SELF-AWARENESS

Competency 3

The professional counselor actively explores his or her own attitudes, beliefs, and values about spirituality and/or religion.

Competency 4

The professional counselor continuously evaluates the influence of his or her own spiritual and/or religious beliefs and values on the client and the counseling process.

Competency 5

The professional counselor can identify the limits of his or her understanding of the client's spiritual and/or religious perspective and is acquainted with religious and spiritual resources and leaders who can be avenues for consultation and to whom the counselor can refer.

Most models of psychotherapy require the enhancement of self-awareness and knowledge on the part of mental health professionals. To function effectively as a counselor, mental health professionals need to know themselves [84,85,86]. Accordingly, counselors should be aware of their own biases, values, beliefs, and assumptions prior to working with culturally diverse clients [27]. Kotter asserts that counselors devalue their profession when they are unable to practice in their own lives what they ask of their clients [85].

McLennan and colleagues identify four integrated processes to assist counselors in becoming more self-aware [27,87]. The first process involves reflecting on how one's attitudes, values, and beliefs have developed over the lifespan. The second process involves the exploration of personal prejudices, biases, doubts, and fears [27]. The third process consists of exploring spirituality/religion and assimilating it into the counseling process through examining the relationship between mind, body, and spirit [27]. The final process involves continuous assessment of one's comfort levels while exploring the spiritual domain with clients, especially when clients' beliefs differ greatly from one's own [27].

EVALUATING THE INFLUENCE OF ONE'S SPIRITUAL AND/OR RELIGIOUS BELIEFS AND VALUES ON THE CLIENT AND THE COUNSELING PROCESS

A counselor has the potential to intentionally or unintentionally influence a client toward his/her own worldview [27]. Therefore, counselors should be mindful and monitor how their values and beliefs might influence the interventions they use in their professional work. If counselors have clarity regarding their values and beliefs, they are less likely to lead their clients toward adopting their values and beliefs. The counselor's task is to provide a nonjudgmental and accepting environment for clients to discuss their religious and spiritual concerns. Counseling does not entail making decisions for the client, teaching them "appropriate" values, or steering clients toward accepting the counselor's perspective [27]. Instead, counselors should keep in mind that the client is responsible for determining which values to maintain, discard, replace, or modify [27].

McLennan et al. suggest counselors engage in self-exploration to determine how their religious and spiritual values and beliefs might impact the therapeutic process [87]. Not doing so could lead to negative consequences, such as [27]:

- Clients feeling their spiritual experiences are not validated

- Counselors overlooking clients' important issues that should be addressed

- Counselors failing to recognize clients' positive spiritual coping resources

In short, counselors must first feel comfortable with their own spiritual and religious values and beliefs before working with clients who want to address spiritual and/or religious issues in counseling [27].

RECOGNIZING LIMITS

The first and most basic limitation for counselors to consider is whether they can work with clients around spiritual or religious concerns [27]. Some counselors may have their own spiritual concerns due to past experiences and may not feel comfortable discussing religious and spiritual issues with clients [27]. Acknowledging any reluctance to address spiritual and/or religious matters is an important step toward understanding one's limitations. Upon noting one's reluctance, growth in comfort and competence is necessary [27].

The second professional limitation to consider involves the assessment of clients' spectrum of spiritual concerns. A client's presenting concern is often related to his/her current spiritual beliefs and practices (e.g. "How can God allow me to feel so much pain in this situation?"). Other times, presenting concerns are influenced by the client's spiritual beliefs and practice (e.g., "Should I have a sexual relationship with my girlfriend?") [27].

A third limitation is clients being challenged by their own or others' beliefs and practices [27]. Some clients may be having a crisis of faith, have experienced spiritual abuse, or may feel unable to achieve the standards of their religion.

Lastly, it is important for counselors to avoid crossing professional boundaries and adopting the role of a religious leader; doing so would interfere with the therapeutic process [27]. Counselors who are self-aware know when to refer a client to spiritual and/or religious community resources. For example, if a client's concern is related to religious doctrine or scripture, a referral to a clergy might be necessary. Counselors should also be familiar with their referral sources and with the spiritual resources in the community [27].

7. HUMAN AND SPIRITUAL DEVELOPMENT

Competency 6

The professional counselor can describe and apply various models of spiritual and/or religious development and their relationship to human development.

Spiritual development has been identified as a normal part of the human development process [27]. To become competent in this area, counselors should be familiar with the various models of spiritual development. Spiritual development models differ in form and usually imply a process of growth over time [27,53]. Some theorists view spiritual development as a continual process, instead of a process of moving from one stage to another [88]. However, most spiritual development models are linear and hierarchical, and each stage of development builds on the previous stage [53]. Usually, individuals must complete each stage successfully before moving to the next stage. Further, each stage is designed to follow a chronologic sequence based on age or life stage [53]. These models are useful because they assist counselors in understanding how clients integrate faith into their lives [53]. Furthermore, they give counselors an idea as to where clients are in their spiritual and religious development [53]. This section will discuss a variety of models of spiritual development, including Allport's theory of faith development, Fowler's Stages of Faith, Oser and Gmunder's religious judgment model, Genia's faith development model, and Washburn's theory of transpersonal development.

ALLPORT'S MODEL

Gordon Allport presented the first model of faith development in 1950 [53]. This model focused on "religious sentiments," which he defined as "religious beliefs (empowered by effective energies) that lead to consonant religious and secular behavior" [89,90]. According to Allport, religious sentiments or beliefs occur in three stages.

Stage 1 of Allport's model is raw credulity. This stage is referred to as authority-based, because persons in this stage (traditionally, prepubescent children) tend to believe whatever their parents or adult authority figures tell them about religion and spirituality [90]. Such blind acceptance of religious doctrine fulfills an individual's need to belong and be accepted by an "in-group" [89]. Many children move into adulthood without questioning the faith they acquire as children, and these beliefs are considered juvenile and illogical [89].

Stage 2 is satisfying rationalism. This usually begins during the turbulence of adolescence. During this stage, individuals start questioning what they have been taught about religion and spirituality and begin to seek an identity separate from their parents [90]. Many individuals enter this stage in their teenage years, becoming rebellious and starting to reject parental values, including religious and/or spiritual ones [89].

Stage 3 is religious maturity. This stage is characterized by the movement between uncertainty and faith [53]. Mature religious sentiment occurs when individuals remain connected to a religious or spiritual tradition but approach it critically [53]. Individuals in this stage discern which beliefs are useful to them and which are not. Useful beliefs are kept, and harmful or non-useful beliefs are discarded [53].

FOWLER'S STAGES OF FAITH

Fowler perceived faith development as an innate part of human development [27]. His theory of faith development is grounded in cognitive development theory. Fowler defines faith as "loyalty to a transcendent center of value and power" and "the force field of life" [91]. Fowler's faith development model was based on a qualitative study of 359 individuals who were interviewed between 1972 and 1981 about religion, values, and life-altering experiences [27,53]. Each interview lasted about 2.5 hours, and participants ranged from 3.5 to 84 years of age. Fowler's theory of faith development is comprised of seven stages.

Stage 1 of Fowler's model is referred to as primal faith, and it occurs during infancy and before language development. At this stage, children experience faith as a connection between themselves and their caregivers. Infants are learning to trust their caregivers to meet their needs. If their needs are met, they gain hope, love, courage, and trust; however, unfulfilled needs lead to narcissism or isolation [91].

Stage 2 is intuitive-projective faith. Children at this stage are between 3 to 7 years of age. Language is emerging, but cognitive processes have not fully developed—these children are incapable of thinking logically and seeing the world from another person's perspective [27,53]. Their internal world centers around fantasy, imagination, and emotions [27]. At this stage, children's images of God are very similar to their parents and other significant others [27].

Stage 3 is mythic-literal faith. Children at this stage are usually elementary and middle-school age. Their cognitive processes are emerging; therefore, their thinking is more logical and they are able to see the world through other people's perspectives. They are now capable of separating fantasy from reality [53]. Children at this stage begin to incorporate the values and beliefs of their culture as guidelines for living [27]. God is perceived as anthropomorphic and the ruler of the universe—one who is fair and rewards good and punishes evil [27].

Stage 4 is synthetic-conventional faith. The majority of persons at this stage are adolescents. These persons can think abstractly, engage in self-reflection, and see themselves through the eyes of others [53]. At this stage, individuals find meaning through group identification. Therefore, they seek belonging through religious institutions, spiritual traditions, family, and ethnic groups [27].

Stage 5 is individuative-reflective faith. This stage is generally comprised of persons in late adolescence to early adulthood [27]. Persons at this stage start to question assumptions around their faith tradition. No longer do they blindly accept the faith of their parents. Some persons leave their religious community to search for answers to their questions. Faith becomes a conscious decision based on critical examination. In the end, the person starts to take greater ownership of his or her faith journey [53].

Stage 6 is conjunctive faith. Persons who arrive in this stage are usually in their 30s [27]. Many have found answers to some of their questions and have learned that two or more truths can exist simultaneously [27]. They have developed their own faith through struggling and questioning. They now acknowledge and embrace multiple perspectives of faith while remaining grounded in their own.

Stage 7 is universalizing faith, and very few people reach this stage. Persons at this stage are committed to universal values such as peace and justice [53]. Moreover, they are "grounded in oneness with the power of being or God" [91].

OSER'S RELIGIOUS JUDGMENT MODEL

Oser's religious judgment model is universal and is based on a cognitive approach to spiritual development [92]. The model occurs in five stages and explains how people understand their relationship with God or the Ultimate Being. According to the model, crisis situations provoke individuals to explore their relationship with God or the Ultimate [65]. Crises usually create disequilibrium in the lives of individuals, causing them to question their relationship with the Ultimate [65]. Consequently, they decide to be open to uncertainty and the opportunity to reconsider this relationship [65]. This is a continuous process whereby people undergo a transformation of faith as they age due to their life experiences [53].

Stage 1 is referred to as the orientation of heteronomy. Persons (usually children) at this stage view God or the Ultimate Being as all-powerful and the cause of everything that happens (good and bad).

Stage 2 is the orientation of do et des.Do et des translated from Latin means "I give and you give" [27]. God continues to be perceived as all-powerful but can be influenced through prayers, vows, rituals, and good deeds [27,65].

Stage 3 is the orientation of ego autonomy and one-side responsibility. In this stage, God or the Ultimate (if such a being exists) is placed within an independent realm of influence separated from human autonomy and responsibility. Thus, both the individual and the Ultimate are independent and free to make decisions.

Stage 4 is mediated autonomy. In this stage, individuals perceive God as having power over all things and as being present in the world. The Ultimate and the individual work in concert according to God's predetermined divine plan [53].

Stage 5 is the orientation of unconditional religiosity. Persons at this stage are aware of the all-pervasiveness of God. They recognize that God "informs each moment and commitment in life, however profane and insignificant" [53].

GENIA'S FIVE-STAGE FAITH DEVELOPMENT MODEL

Genia's Five-Stage Faith Development Model has its origin in psychoanalytic theory. The model depicts the progression of faith through five stages, beginning with egocentric faith and ending with transcendent faith. According to this theory, the progression of faith development is not always linear nor does it always run smoothly [53]. When individuals are undergoing crises or when their needs have not been met for a period of time, they tend to regress to less mature coping strategies [93]. Emotional difficulties can cause persons to seek out toxic forms of faith, and traumatic experiences can prevent them from progressing to the next stage [93].

Stage 1 of Genia's model is egocentric faith. In this stage, one's religion is rooted in fear and a need for comfort [53]. Usually, adults in this stage have survived abuse or neglect and have difficulty forming trusting relationships with others or with God [53,65]. Disappointments or emotional pain cause these persons to feel tormented by God. Adults at this stage typically use prayer as a means of seeking God's favor and manipulating God to protect them [65].

Stage 2 is dogmatic faith. Persons at this stage are continually trying to earn the approval of God [65]. They adhere to religious and spiritual laws out of fear of disappointing God and forfeiting the reward of eternal blessing.

Stage 3 is transitional faith. Persons in this stage are critically examining their faith. They may experiment with different spiritual paths, trusting their own conscience instead of religious dogma. During this period of experimenting with various spiritual paths, individuals often feel alone and disconnected [65]. People at this stage of faith might switch religious denominations or might investigate a variety of other spiritual experiences prior to adopting a meaningful spiritual orientation [53,65].

Stage 4 is reconstructed faith. Persons at this stage have matured and have chosen a faith that provides meaning and purpose and suits their spiritual needs. Because they are driven by their own morals and ideas, they perceive God as a reliable friend and source of sustenance [53,65]. Therefore, they are grateful, acknowledging their wrongdoings, seeking forgiveness, and making amends when possible [65].

Stage 5 is transcendent faith; most individuals do not reach this stage. Persons who do reach this stage are usually more mature spiritually and are committed to universal ideals and are devoted to truth and goodness [53]. They feel a sense of connection with others of diverse faiths, have a relationship with God, and apply spiritual principles to their lives [53].

WASHBURN'S THEORY OF PSYCHOSPIRITUAL DEVELOPMENT

Washburn's theory of psychospiritual development is based on psychoanalytic theory and transpersonal psychology [27,94]. According to Washburn, the primary aim of human development is spiritual fulfillment [27]. He envisioned spiritual fulfillment resulting from the interplay between the ego (personal aspect) and the Dynamic Ground (spiritual aspect), which is a lifelong process. During this interplay, the ego functions receptively (moves closer to the Ground) or actively (moves away from the Ground) [27]. The interplay between the ego and the Dynamic Ground continues throughout the developmental process as both evolve through the three stages [27].

Stage 1 of Washburn's theory is the pre-egoic phase. This stage begins at birth and continues to pre-latent childhood [27]. At this stage, the ego is totally immersed in the Dynamic Ground and, therefore, in the receptive mode of functioning. After birth, the ego becomes more active, as it begins to differentiate itself from the Dynamic Ground through repression [27]. During latency, the ego has completely separated itself from the Dynamic Ground.

Stage 2 is the egoic phase. During this stage, the ego functions primarily in the active mode, as it becomes more autonomous while the Dynamic Ground recedes into unconsciousness. Persons may remain in this stage for their entire lives. Around midlife, individuals with highly evolved egos feel less threatened and begin to relax repression of the Dynamic Ground. Once relaxed and secure, the ego begins to reconnect with the Ground for the purpose of transcendence.

Stage 3 is called the transegoic phase. During this stage, reconnection with the Ground leads to emotional and functional difficulties, which brings about a spiritual awakening [27]. If the transegoic stage is allowed to proceed, the ego begins mastering both receptive and active functioning, sometimes simultaneously. This occurs through drawing from the Dynamic Ground and becoming increasingly empowered [27]. The individual who has learned to integrate opposites (i.e., active and receptive) is said to be demonstrating advanced development potential [27].

LIMITATIONS OF MODELS OF RELIGIOUS/SPIRITUAL DEVELOPMENTAL

No models of religious and/or spiritual development are all-encompassing. A major criticism of these models is that they tend to promote the notion of "developmental progression" [53]. While some assert that the stages in these models are simply ways of organizing shared traits, to some theorists the stage-wise approach seems to imply that individuals at higher stages in the models are more valued than those at a lower stage [53]. In structures that are linear and hierarchical, it is difficult not to conclude that higher stages are more valued [53].

Nevertheless, understanding the various spiritual developmental models can be of great value in the counseling process. Such models can serve as a reference point for both the counselor and the client and can help both parties anticipate and even facilitate the client's developmental progress [27].

8. COMMUNICATION

Competency 7

The professional counselor responds to client communication about spirituality and/or religion with acceptance and sensitivity.

Competency 8

The professional counselor uses spiritual and/or religious concepts that are consistent with the client's spiritual and/or religious perspective and that are acceptable to the client.

Competency 9

The professional counselor can recognize spiritual and/or religious themes in client communication and is able to address these with the client when they are therapeutically relevant.

Most mental health professionals agree that discussing religious and spiritual matters in counseling, when appropriate, is desirable and "a necessary component of holistically addressing clients' needs" [27]. However, the best way to communicate with clients about religion and spiritual matters remains under-explored [27]. Counselor training programs have historically neglected spiritual issues due to the belief that religion and education should be separated [27]. Consequently, students did not receive vital training to address spiritual matters in counseling. This lack of knowledge can hinder effective communication, which may cause the client to feel that the counselor is insensitive or not receptive to discussing religious or spiritual matters [27].

The ability to intensify clients' exploration of their spirituality relies on the counselor's communication skills [27]. Spirituality is very personal, and deeper exploration of a client's spirituality can be very therapeutic, especially when counselors express genuine interest in client beliefs [27]. Effective communication regarding spiritual and religious issues involves avoiding four common barriers to miscommunication. The first type of miscommunication occurs when counselors do not accurately convey spiritual or religious content discussed in the session [27]. Second, counselors may also be inconsistent or incongruent with their communications. Third, counselors may struggle with limitations and complexities inherent in the language clients use when discussing their religious and/or spiritual beliefs [27]. Finally, counselors may inappropriately express judgment or disapproval of clients' beliefs and values [27]. Avoiding these four types of miscommunication will lead to a more trusting therapeutic relationship. Clients may feel discouraged from discussing spiritual or religious issues when counselors are not consistent in their communication of being open to exploring client spirituality [27]. Openness and consistency should start at the beginning of the counseling session, preferably during the intake process [53].

Another key element of effective communication is matching the client's language or terminology [27]. For example, if a client uses Allah in reference to God, counselors should do the same rather than using another comparable term, such as Higher Power [27]. Using words outside of the client's frame of reference during counseling can damage the therapeutic relationship [27]. Often, clients will not feel comfortable initiating discussion about spiritual concerns in counseling and will use indirect messages of spirituality instead [27]. Therefore, counselors should listen for spiritual themes, which can take many forms. These themes may be centered around ideas of the sacred, a belief in a just universe, death or loss, and/or finding meaning and purpose [27].

Other factors that influence spiritual communication and the developmental process include gender, age, race, ethnicity, family, and sexuality [27]. Both explicit and implicit gender-laden messages can affect how individuals' spiritual and religious identities develop. Religious teachings may conflict with a client's sexual orientation and present a spiritual concern for the client. [27]. Also, clients of different ages may be in different stages of spiritual development. For example, older adults may use faith to cope when considering their own mortality [27].

9. ASSESSMENT

Competency 10

During the intake and assessment processes, the professional counselor strives to understand a client's spiritual and/or religious perspective by gathering information from the client and/or other sources.

Both spiritual assessments and informed consents are needed prior to incorporating spirituality or religion into therapy. A primary function of a spiritual assessment is to determine whether religious or spiritual issues are germane to the client's presenting problem or to ascertain if the presenting problem is spiritual or religious in nature [62]. There are a variety of purposes to assess the client's religious and spiritual perspective, including to [15]:

- Understand the client's worldview

- Obtain knowledge as to how healthy the client's perspective is and how it is related to counseling issues

- Identify positive resources of beliefs and support

- Determine possible interventions that can be used in counseling

- Clarify the level of need to address spiritual or religious views in counseling

The intake process and the clinical interview are usually the first steps in the spiritual assessment process [53]. Both the intake and the clinical interview give counselors the opportunity to learn about the client, the client's concerns, and the client's worldview (including spiritual and religious perspectives) [27,53]. Information gathered during the intake process usually includes demographic information, a description of the presenting problem, current problem-solving techniques, medical history, mental health status, and family background [53]. When conducting an assessment of the client's spiritual and/or religious perspective, certain factors should be considered, such as family religious and/or spiritual history, its impact on the client's upbringing, and the client's past experiences with spiritual or religious issues [62,95].

Counselors can assess their clients' spirituality utilizing intake questionnaires or counseling interviews [96]. Questions one might consider asking at intake include [96]:

- Would you like to discuss spiritual matters in counseling when relevant?

- Do you believe in God or a higher power?

- What is God like to you?

- Is spirituality important to you?

- Do you have a religious affiliation? If so, how important is it?

- Do you attend a place of gathering, such as a church, mosque, temple, or synagogue?

- How closely do you, and your family, follow the teachings of your religion?

- How do you personally experience God's guidance?

- Do you have any concerns related to your spirituality or religious community?

In addition, the Joint Commission has offered spirituality intake assessment questions that may be directed toward a client and/or family members for those receiving psychosocial services for substance use disorders (including alcohol use disorder) and/or end-of-life care. Examples to consider, but not prescriptively required by the Joint Commission, include [51]:

- Who or what provides the client with strength and hope?

- Does the client use prayer in their life?

- How does the client express their spirituality?

- How would the client describe their philosophy of life?

- What type of spiritual/religious support does the client desire?

- What is the name of the client's clergy, ministers, chaplains, pastor, rabbi?

- What does suffering mean to the client?

- What does dying mean to the client?

- What are the client's spiritual goals?

- Is there a role of church/synagogue in the client's life?

- How does your faith help the client cope with illness?

- How does the client keep going day after day?

- What helps the client get through this healthcare experience?

- How has illness affected the client and his/her family?

When gathering spiritual information about the client, it is important to remember that the focus should be on the whole person and not just on the client's presenting problem or spiritual concerns [27]. Humans are multidimensional; therefore, a client's physical, emotional, spiritual, and environmental dimensions should all be taken into consideration during an assessment [27]. Information gathering should include verbal and nonverbal communication. For example, counselors may obtain some information through observing client appearance (e.g., head coverings, religious symbols, wedding rings) [27].

A spiritual genogram is another way of assessing the spiritual domain in families. It gives clients a multigeneration view by enabling clients to understand their families' religious/spiritual heritage and recognize ways in which their families' experiences impact current issues in their lives [53,103]. Spiritual ecomaps can also be used with clients to assess the spiritual domain of the client's immediate family when necessary [95]. Usually, a family's spiritual genogram is located in the center of the spiritual ecomap, with other subsystems relevant to the family located outside of the family circle [95].

10. DIAGNOSIS AND TREATMENT

Competency 11

When making a diagnosis, the professional counselor recognizes that the client's spiritual and/or religious perspectives can a) enhance well-being; b) contribute to client problems; and/or c) exacerbate symptoms.

Competency 12

The professional counselor sets goals with the client that are consistent with the client's spiritual and/or religious perspectives.

Competency 13

The professional counselor is able to a) modify therapeutic techniques to include a client's spiritual and/or religious perspectives, and b) utilize spiritual and/or religious practices as techniques when appropriate and acceptable to a client's viewpoint.

Competency 14

The professional counselor can therapeutically apply theory and current research supporting the inclusion of a client's spiritual and/or religious perspectives and practices.

When making a diagnosis, it is important to remember that positive or healthy spiritual beliefs may enhance well-being while negative or unhealthy spiritual beliefs can contribute to the problem by diminishing hope and instilling fear. When working in the realm of spirituality and mental health, the risk of misdiagnosis increases [27]. Counselors who are spiritually and religiously oriented tend to be more inclined to underdiagnose clients, while counselors who adhere to a biomedical model may overlook spiritual influences and/or diagnose them as treatable disorders [27]. A counselor who lacks understanding of transformative processes may pathologize spiritual experiences rather than contextualizing them as spiritual and/or religious [27]. Conversely, counselors who shy away from diagnosing clients may be more likely to label a diagnosable disorder as a spiritual experience [27]. Essentially, it is vital for counselors to be able to discern diagnosable mental disorders/symptoms and spiritual experiences [27].

A diagnostic category V62.89 Religious and Spiritual Problems was proposed by transpersonal clinicians to address this concern and subsequently added to the fourth revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and carried over to the fifth revised edition (DSM-5-TR) [97,102]. Examples of religious and spiritual problems include [97]:

- Crisis of faith

- Conversion to a new faith

- Life-threatening or terminal illness

- Guilt and shame resulting from membership in a religious cult

In some cases, spiritual or religious problems co-occur with a psychiatric disorder [27,97]. For example, obsessive-compulsive disorder may manifest as religious or spiritual [27]. An extreme version of this is moral or religious scrupulosity, an obsessive concern with one's sins and moral behavior [27]. Treatment of this disorder is difficult, as practitioners often feel torn between addressing the pathology of the disorder and respecting the patient's religious beliefs or practices.

In some instances, spiritual or religious concerns are merely due to psychopathology. Patients with psychotic disorders may experience delusions and hallucinations with religious content, and focusing on religion might exacerbate symptoms of disorganized thought and potentially promote injury to self or others [98,99,100].

Evidence Based Practice Recommendation

The American Academy of Child and Adolescent Psychiatry recommends clinicians consider consulting and collaborating with traditional healers (e.g., curanderos, santeros, or shamans) and including rituals and ceremonies in psychotherapy with children from more traditional backgrounds.

https://www.aacap.org/App_Themes/AACAP/Docs/practice_parameters/Cultural_Competence_Web.pdf

Last Accessed: May 25, 2023

Level of Evidence: Consensus Statement/Expert Opinion

Counseling goals should be clear, observable, measurable, and attainable so sessions do not appear aimless. Moreover, these goals should be consistent with the client's belief system [27]. Clients' participation in goal setting is very important, and goal setting for spiritual and religious matters should come primarily from the client. There are three types of outcome goal settings to keep in mind throughout the counseling process: collaborative goals, counselor process goals, and spiritual and religious goals [27]. Collaborative goals are developed by the client and the counselor together [27]. Counselor process goals are developed by the counselor for their work with clients, the therapeutic relationship, and the process [27]. Usually, these goals are not shared directly with the client. Spiritual and religious goals are developed for the client's spiritual and/or religious growth. These goals tend to be less specific or behavioral, which makes outcomes difficult to measure [27].

Competently treating spirituality concerns requires counselors to modify therapeutic techniques to include clients' spiritual and religious perspectives [27]. One way to do this is through experiential focusing, a process developed by Gendlin to access and integrate spiritual experiences [27,101]. Encouraging adjunctive spiritual practices (e.g., spiritual journaling, mindfulness techniques, meditation, prayer) can be useful as well, depending on the client's belief system. Counselors can also encourage the use of spiritual practices during sessions by leading clients through a guided meditation [27]. There are many presenting problems and situations in which spiritual or religious exploration would be beneficial, including clients who present with depression, substance abuse, and terminal illness [27]. However, it is always important to consider clients' beliefs and comfort levels using spiritual or religious techniques and practices in the counseling setting.

11. CONCLUSION

There is a growing recognition of the importance of the spiritual domain in the counseling process and the need for training materials and strategies for integrating the ASERVIC competencies into the field of counseling. Although many mental health professionals and educators endorse the spiritual competencies, additional resources can help clarify the role of these competencies in everyday practice.

This course has summarized the revised ASERVIC competencies, their relevance, and application in the counseling process. It is important for counselors to be proficient in each area before working with spiritual and religious issues with clients. These competencies will enable counselors, mental health professionals, and allied health professionals to develop a framework to assist them in understanding and working effectively with clients' spiritual and religious lives.

Works Cited

1. Ghaderi A, Tabatabaei SM, Nedjat S, Javadi M, Larijani. Explanatory definition of the concept of spiritual health: a qualitative study in Iran. J Med Ethics Hist Med. 2018;11:1-7.

2. Vieten C, Scammell S, Pilato R, et al. Spiritual and Religious Competencies for Psychologists. Available at https://www.apa.org/pubs/journals/features/rel-a0032699.pdf. Last accessed May 1, 2023.

3. Fisher J. The four domains model: connecting spirituality, health and well-being. Religions (Basel). 2011;2(1):17-28.

4. Frankl V. Man's Search for Meaning. Boston, MA: Beacon Press: 2019.

5. Pargament KI. The Psychology of Religion and Coping: Theory, Research, Practice. New York, NY: The Guilford Press; 1997.

6. 6. Association of Spiritual, Ethical, and Religious Values in Counseling. ASERVIC White Paper. Available at https://aservic.org/wp-content/uploads/2021/04/ASERVIC-WHITE-PAPER.pdf. Last accessed May 1, 2023.

7. Myers JE, Sweeney TJ, Witmer JT. The wheel of wellness counseling for wellness: a holistic model for treatment planning.J Couns Dev. 2000;78(3):251-266.

8. Fehring R, Miller J, Shaw C. Spiritual well-being, religiosity, hope, depression, and other mood states in elderly people coping with cancer.Oncol Nurs Forum. 1997;24(4):663-671.

9. Koenig HG, Larson DB. Religion and mental health: evidence for an association.Int Rev Psychiatry. 2001;13(2):67-78.

10. Hussain D. Spirituality, religion and health: reflections and issues.Eur J Psychol. 2011;7(1):187-197.

11. Nichols LM, Hunt B. The significance of spirituality for individuals with chronic illness: implication for mental health counseling.J Ment Health Couns. 2011;33(1):51-66.

12. Hodges S. Mental health, depression, and dimensions of spirituality and religion.J Adult Dev. 2002;9:109-115.

13. Koenig H, Pritchett J. Religion and psychotherapy. In: Koenig HG (ed).Handbook of Religion and Mental Health. San Diego, CA: Academic Press; 2002: 323-336.

14. Levin J.God, Faith, and Health: Exploring the Spirituality-Healing Connection. New York, NY: John Wiley & Sons; 2001.

15. Richards PS, Bergin AE. A spiritual strategy for counseling and psychotherapy. In: Miller G (ed).Incorporating Spirituality in Counseling and Psychotherapy. Washington, DC: American Psychological Association; 2002: 145.

16. Brewer-Smyth K, Koenig HG. Could spirituality and religion promote stress resilience in surviors of childhood trauma?Issues Ment Health Nurs. 2014;35(4):251-256.

17. Faigin C, Pargament KI. Strengthened by the spirit: religion, spirituality, and resilience through adulthood and aging.Resilience in Aging. 2011;163-180.

18. Reiner SM. Religious and spiritual beliefs: an avenue to explore end-of-life issues.Adultspan Journal. 2007;6(2):111-118.

19. Bassett H, Lloyd C, Tse S. Approaching in the spirit: spirituality and hope in recovery from mental health problems.Int J Ther Rehabil. 2008;15(6):254-261.

20. Koenig HG. Religion and mental health: what should psychiatrists do?Psychiatr Bull. 2008;32(6):201-203.

21. Jones A, Cohen D, Johnstone B, et al. Relationships between negative spiritual beliefs and health outcomes for individuals with heterogeneous medical conditions.J Spiritual Ment Health. 2015;17(2):135-152.

22. Russinova Z, Cash D. Personal perspectives about the meaning of religion and spirituality among persons with serious mental illnesses.Psychiatr Rehabil J. 2007;30(4):271-284.

23. Robertson L. The Spiritual Competency Scale: A Comparison to the ASERVIC Spiritual Competencies. Available at https://stars.library.ucf.edu/etd/3549. Last accessed May 1, 2023.

24. National Alliance on Mental Illness. Mental Health by the Numbers. Available athttps://www.nami.org/mhstats. Last accessed May 1, 2023.

25. The White House. Issue Briefs: Reducing the Economic Burden of Unmet Mental Health Needs. Available at https://www.whitehouse.gov/cea/written-materials/2022/05/31/reducing-the-economic-burden-of-unmet-mental-health-needs. Last accessed May 1, 2023.

26. Hagedorn WB, Gutierrez D. Integration versus segregation: applications of the spiritual competencies in counselor education programs.Couns Values. 2009;54(1):32-47.

27. Cashwell CS, Young JS.Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020.

28. 28. Ingersoll RE. Teaching a course on counseling and spirituality.Counselor Education & Supervision. 2011;36(3):224-232.

29. Curtis R, Glass J. Spirituality and counseling class: a teaching model.Couns Values. 2002;4(1):3-12.

30. Fukuyama MA, Sevig TD. Spiritual issues in counseling: a new course.Counselor Education & Supervision. 2011;36(3):233-244.

31. Jackson ML. Multicultural counseling: historical perspective. In: Ponterotto G, Casas J, Suzuki LA, Alexander CM (eds).Handbook of Multicultural Counseling. 4th ed. Los Angeles, CA: Sage; 2017: 3-16.

32. Sue D, Bernier J, Durran A, et al. Position paper: cross-cultural counseling competencies.Couns Psychol. 1982;1(2):45-52.

33. 33. Sue DW, Arredondo P, McDavis R. Multicultural counseling competencies and standards: a call to the profession.J Couns Dev. 1992;70(4):177-183.

34. Moore S. A Strategic U.S. Policy for the New Economy. Available at https://cis.org/Report/Strategic-US-Immigration-Policy-New-Economy. Last accessed May 1, 2023.

35. Sue DW, Sue D.Counseling the Culturally Diverse: Theory and Practice. 8th ed. Hoboken, NJ: John Wiley and Sons; 2019.

36. Migration Policy Institute. Frequently Requested Statistics on Immigrants and Immigration in the United States. Available at https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states. Last accessed May 1, 2023.

37. Skerry P. Do we really want immigrants to assimilate?Society. 2000;37(3):57-62.

38. Aten JD, Hernandez BC. Addressing religion in clinical supervision: a model.Psychotherapy (Chic). 2004;41(2):152-160.

39. 39. Worthington EL, Sandage SJ. Religion and spirituality.Psychotherapy. 2011;38(4):473-479.

40. Lindgren KN, Coursey RD. Spirituality and serious mental illness: a two-part study.Psychiatr Rehabil J. 1995;18(3):93-111.

41. Pew Research Center. Key Findings About Americans' Belief in God. Available at https://www.pewresearch.org/short-reads/2018/04/25/key-findings-about-americans-belief-in-god. Last accessed May 1, 2023.

42. Belaire C, Young J. Influences of spirituality on counselor selection.Couns Values. 2000;44(3):189-197.

43. Kelly EW. The role of religion and spirituality in counselor education: a national survey.Counselor Education & Supervision. 1994;33(4):227-237.

44. Mack ML. Understanding spirituality in counseling psychology: considerations for research, training, and practice.Couns Values. 1994;39(1):15-32.

45. Pate H Jr, Bondi AM. Religious beliefs and practice: an integral aspect of multicultural awareness.Counselor Education & Supervision. 1992;32(2):108-115.

46. Weinstein C, Parker J, Archer J. College counselors' attitudes toward spiritual and religious issues and practice in counseling.Journal of College Counseling. 2002;5(2):164-174.

47. Shafranske E, Maloney H. Clinical psychologists' religious and spiritual orientations and their practice of psychotherapy.Psychotherapy. 1990;27(1):72-78.

48. American Counseling Association. ACA Code of Ethics. Available at https://www.counseling.org/resources/aca-code-of-ethics.pdf. Last accessed May 1, 2023.

49. American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text revision. Washington, DC: American Psychiatric Association; 2013.

50. Council for Accreditation of Counseling and Related Educational Programs. 2016 CACREP Standards. Available at https://www.cacrep.org/for-programs/2016-cacrep-standards. Last accessed May 1, 2023.

51. The Joint Commission. Spiritual Beliefs and Preferences: Evaluating a Patient's Spiritual Needs. Available at https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/provision-of-care-treatment-and-services-pc/000001669. Last accessed May 1, 2023.

52. Miller G. The development of the spiritual focus in counseling and counselor education.J Couns Dev. 2011;77(4):498-501.

53. Wiggins-Frame M.Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning: 2003.

54. Cashwell C, Watts R. The new ASERVIC competencies for addressing spiritual and religious issues in counseling.Couns Values. 2010;51:2-5.

55. Elkins DN. Spirituality.Psychol Today. 1999;32:44-47.

56. 56. Hill PV, Pargament KI, Hood RW Jr., et al. Conceptualizing religion and spirituality: points of commonality, points of departure.J Theory Soc Behav. 2000;30(1):51-77.

57. Oxhandler HK, Moffatt KM, Giardina TD. Clinical helping professionals' perceived support, barriers, and training to integrate clients' religion/spirituality in practice.Spiritual Clin Pract. 2019;6(4):279-291.

58. Kelly EW.Spirituality and Religion in Counseling and Psychotherapy: Diversity in Theory and Practice. Alexandria, VA: American Counseling Association: 1995.

59. Pargament KI.Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred. New York, NY: The Guilford Press; 2011.

60. Ellison CG, George LK. Religious involvement, social ties, and social support in a southeastern community.J Sci Study Relig. 1994;33(1):46-61.

61. 61. Dilthey W. Dilthey's philosophy of existence: introduction to Weltanschauungslehre. In: Cashwell CS, Young DS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020.

62. Miller G.Incorporating Spirituality in Counseling and Psychotherapy. New York, NY: John Wiley & Sons; 2003.

63. Fishbane M. Judaism: revelation and traditions. In: Cashwell CS, Young DS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020: 44.

64. Morrison M, Brown S. Judaism: a guide to competent practice. In: Cashwell CS, Young DS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020: 44.

65. Gold JM.Counseling and Spirituality: Integrating Spiritual and Clinical Orientations. Upper Saddle River, NJ: Pearson; 2010.

66. 66. Frankiel S. Christianity: a way to salvation. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 65.

67. Rahman F. Islam, Encarta Encyclopedia. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 68.

68. Hedayat-Diba Z. Psychotherapy with Muslims. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 69.

69. O'Flaherty WD. Hinduism. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 70.

70. Wangu MB. Hinduism. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 70.

71. 71. Pew Research Center. The Future of World Religions: Population Growth Projections, 2010–2050. Available at https://www.pewforum.org/2015/04/02/religious-projections-2010-2050. Last accessed May 1, 2023.

72. Sharma AR. Psychotherapy with Hindus. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 70.

73. McDermott JP. Buddhism. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 72.

74. Wangu MB. Buddhism. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 73.

75. Lester RC. Buddhism: the path to Nirvana. In: Cashwell CS, Young DS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020: 49-50.

76. Smith H. The religious man. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003.

77. Liu WC. Confucianism.: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 75.

78. Hartz PR. Taoism. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 76.

79. Hartz PR. Shinto. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 77.

80. Watts AW. Shinto. In: Cashwell CS, Young DS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020: 51.

81. Earhart HB. Religion of Japan: many traditions, one sacred way. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003.

82. Heelas P.The New Age Movement: The Celebration of the Self and the Sacralization of Modernity. Oxford: Blackwell; 2005.

83. Heelas P, Woodhead L.The Spiritual Revolution: Why Religion is Giving Way to Spirituality. Oxford: Blackwell Publishing; 2018.

84. Capuzzi D, Gross DR. Achieving and personal and professional identity. In: Gold J (ed).Counseling and Spirituality: Integrating Spiritual and Clinical Orientations. Upper Saddle River, NJ: Pearson Education Inc.; 2007: 32.

85. Kottler JA.Nuts and Bolts of Helping. Boston, MA: Allyn and Bacon; 2000.

86. Schneider-Corey M.Groups: Process and Practice. 10th ed. Boston, MA: Cengage Learning; 2018.

87. McLennan NA, Rochow S, Arthur N. Spiritual and religious diversity in counseling.Guid Counc. 2001;16:132-137.

88. Hood R, W Spilka Jr, Hunsberger B.The Psychology of Religion: An Empirical Approach. New York, NY: Guilford; 2018.

89. Allport GW. The individual and his religion. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 37-38.

90. Worthington EL. Religious faith across lifespan: implications for counseling and research. Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning;37.

91. Fowler JW. Stages of faith: the psychology of human development and the quest for meaning. In: Cashwell CS, Young DS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020: 98-99.

92. Oser FK. The development of religious judgment. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 45-46.

93. Genia V. Counseling and psychotherapy of religious clients: a developmental approach. In: Wiggins-Frame M (ed).Integrating Religion and Spirituality Into Counseling: A Comprehensive Approach. Pacific Grove, CA: Brooks/Cole-Thomson Learning; 2003: 47-49.

94. Washburn M. The ego and the dynamic ground: a transpersonal theory of human development. In: Cashwell CS, Young DS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020: 102-103.

95. Gills CS, Harper MC, Dailey SF. Assessing the spiritual and religions domain. In: Cashwell CS, Young DS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020: 44.

96. Richards PS, Bartz JD, O'Grady KA. Assessing religion and spirituality in counseling: some reflections and recommendations.Couns Values.2009;54(1):65-79.

97. Turner R, Lukoff D, Barnhouse M, Lu F. Religious or spiritual problem: a culturally sensitive diagnostic category in the DSM-IV.J Nerv Ment Dis. 1995;183(7):435-444.

98. Heffernan S, Neil S, Thomas Y, Weatherhead S. Religion in the recovery journey of individuals with experience of psychosis.Psychosis. 2016;8(4):346-356.

99. Fallot RD. Spirituality and religion in psychiatric rehabilitation and recovery from mental illness.Int Rev Psychiatry. 2001;13(2):110-116.

100. Koenig HG. Research on religion, spirituality, and mental health: a review.Can J Psychiatry. 2009;54(5):283-291.

101. >Gendlin E. Focusing. In: Cashwell CS, Young DS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020: 174.

102. American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text Revision. Washington, DC: American Psychiatric Association; 2022.

103. Wiggins-Frame M. The spiritual genogram in family therapy.J Marital Fam Ther. 2007;26(2):211-216.

104. Finn M, Rubin JB. Psychotherapy with Buddhists. In: Cashwell CS, Young JS (eds).Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice. 3rd ed. Alexandria, VA: American Counseling Association; 2020: 49.

105. Association for Multicultural Counseling and Development. Multicultural and Social Justice Counseling Competencies (MSJCC). Available at https://www.multiculturalcounselingdevelopment.org/competencies. Last accessed May 1, 2023.

Evidence-Based Practice Recommendations Citations

1. Pumariega AJ, Rothe E, Mian A, et al. Practice parameter for cultural competence in child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry. 2013;52(10):1101-1115. Available at https://www.aacap.org/App_Themes/AACAP/Docs/practice_parameters/Cultural_Competence_Web.pdf. Last accessed May 25, 2023.