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Perceptions of Clients and Counseling

Professionals Regarding Spirituality in


Counseling
Julie Q. Morrison, Stacy M. Clutter, Elaine M. Pritchett,
and Alan Demmitt
Although current research indicates that psychotherapeutic change both
affects and is attected by spirituai concerns, reiativeiy iittie is known about
the degree to which spirituaiity is used as an intervention in counseiing and
how it is perceived by ciients and mental health protessionais. The purpose
ot this study was to examine the perceptions ot ciients and professionais
regarding the use ot spirituaiity in counseiing. The resuits suggest that more
protessionais may be using spirituaiity in counseiing than has previously
been reported.

any individuals in today's society are pursuing a journey of spiritual


development consistent with their belief that spirituality is vital
for growth and essential for dealing with life's problems (Sperry,
2003). Approximately 95% of Americans polled declared that they believe
in God or a Higher Power (Gallup & Lindsay, 1999), and many have stated
that their faith is a central guiding force in their lives (Gallup, 1995). There
are also signs that public interest in spirituality is rising. Recent research
indicates that approximately 75% of Americans surveyed report that religion
and spirituality are important to them (University of Pennsylvania, 2003).
In keeping with this national trend, it is not surprising that there has been
a movement among clients who are seeking to deal with spiritual issues and
concerns in the context of counseling. Two thirds of Gallup respondents indicated that they would prefer to see a counselor who held similar spiritual
values and beliefs (Lehman, 1993), and it has been noted that clients are increasingly expecting that counselors will treat their spiritual concerns (Sperry,
2003). As a result, many mental health professionals are now considering
the healing potential of a holistic view of mind, body, and spirit when it is
incorporated into the therapeutic process (La Torre, 2002).

Defining Spirituality
Various definitions of the word spirituality exist in the professional literature, and there is little agreement on either the reality or the nature of the
Julie Q. Morrison, College of Education, Criminal justice, and Human Services, University of Cincinnati; Stacy M. Clutter, Kline and Associates, Dayton, Ohio; Elaine M. Pritchett, South Community
Behavioral Healthcare, Dayton, Ohio; Alan Demmitt, Department of Counselor Education and Human
Services, University of Dayton. Correspondence concerning this article should be addressed to Julie Q.
Morrison, College of Education, Criminal justice, and Human Services, University of Cincinnati, PO
Box 210002, Cincinnati, OH 45221-0002 (e-mail: julie.Morrison@uc.edu).

2009 by the American Counseling Association. All rights reserved.


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boundaries between religion and spirituality (Stanard, Sandhu, & Painter,


2000). Religion and spirituality are both thought to relate to the sacred, yet
spirituality is usually described as a more subjective experience, and religion
is defined as a set of beliefs or doctrines that are institutionalized (Stanard
et al., 2000). The Association for Spiritual, Ethical and Religious Values in
Counseling (1998) defined spirituality as "the drawing out and infusion of
spirit in one's life" (para. 3), which involves an innate "capacity for creativity, growth, and development of a value system" (para. 4).

Use of Spiritunlitv in P.svchnlnginal Prncticft


Over the last 20 years, the role of religion in counseling and psychotherapy
has become an important topic for discussion with serious implications for
training and professional development (Worthington, Kurusu, McCullough,
& Sandage, 1996; Young, Wiggins-Frame, & Cashwell, 2007). Not incorporating issues of spirituality and religion into counseling is to ignore an essential
aspect of a client's life (Burke et al., 1999; Frame, 2003; Yoimg et al., 2007). As
a result, mental health professionals are starting to recognize the role that
religion and spirituality can play in emotional well-being (Cashwell, 2001;
Davis, Kerr, & Kurpius, 2003).
Although the majority of mental health professionals report that client
spirituality is an important area of functioning, most do not routinely assess
this topic or address it in treatment planning (Hathaway, Scott, & Carver,
2004). The recognition that the spiritual domain does not seem to be receiving an adequate level of clinical attention in routine practice may be due to
mental health professionals' own disbeliefs in the spiritual realm, lack of
education on the subject, or other unknown reasons (Cubi, 2004; La Torre,
2002; Miovic, 2004). Ethical considerations are also cited as a rationale for
eschewing spirituality as a counseling component (Steen, Engels, & Thweatt,
2006). Caution is appropriate because of the dangers of abusing or misusing
the spiritual direction in psychotherapy (Tan, 2003). Stifoss-Hanssen (1999)
argued that counselors and psychotherapists risk violating the limits of their
professional competence in attempting to deal with spirituality, because
matters of Cod fall into the realm of religion, and matters of religion should
remain with clergy and theologians, not therapists. In their well-known text
on a spiritual strategy for counseling, Richards and Bergin (1997) discussed
several potential ethical concerns including religious and professional dual
relationships, shifting or usurping religious authority, imposing religious
values on clients, violating professional boundaries, practicing outside the
boundaries of professional competence, becoming caught up in superstition,
and trivializing the sacred. Likewise, Tan (1994) warned of the ethical risks
of neglecting to provide the client with adequate information regarding
therapy, focusing largely on religious goals rather than therapeutic goals,
and thus obtaining third-party reimbursement inappropriately, quarrelling
over doctrinal issues rather than clarifying them, and using only spiritual

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interventions for problems that may require medication or other medical or


psychological treatments.
More recently, ethical considerations have been used to make a case for the
need to address spirituality in counseling. Not only is the use of spirituality in counseling appropriate and consistent with the American Counseling
Association (ACA; 1995, 2005) code of ethics, but exploring spirituality in
counseling can promote client growth and welfare (Steen et al., 2006). As
such, counselors are ethically obligated to recognize the dimensions of client spiritually. Counselors who have rigid ideas about spirituality should
include clear statements about their spiritual or atheistic beliefs in informed
consent (Steen et al., 2006). Delicate and multifaceted issues as spiritual beliefs require counselors to unite with clients in creating an atmosphere that
is open and flexible to exploration and questioning.
Both the American Psychological Association and ACA have included religion
and spirituality as a diversity issue, thus requiring mental health professionals
to attend to the importance of religious and spiritual concerns in understanding
and treating clients (Cheston, Piedmont, Eanes, & Lavin, 2003). Therefore, to
the extent that a client's spiritual and religious beliefs and values are pertinent
to the cUent's issues, they deserve the same respectful, ethical, and skillful
attention as any other personal belief or value (Kelly, 1995).

Mental Health Professionals' Perceptions


of Spirituaiity in Counseiing
Recent research has emerged concerning mental health professionals'
perceptions of addressing spirituality in counseling. A survey of 505 ACA
members revealed that the respondents reported moderate to high levels of
agreement regarding the importance of the nine competencies for spiritual
issues in counseling with percentages of respondents who agreed or strongly
agreed with each competency ranging from 51% to 92% (Young et al., 2007).
Slightly more than half (53%) of the respondents agreed or strongly agreed
that they were prepared to practice in accord with the nine competencies for
spiritual issues in counseling (Young et al., 2007). This finding was consistent
with previous research that reported that 73% of surveyed licensed professional counselors judged spiritual interventions in therapy to be important
or vitally important but did not feel competent using these interventions
(Hickson, Housley, & Wages, 2000). Likewise, in a study of counseling
students' perceptions of the use of spirituality in counseling, respondents
had difficulty defining spirituality, reported that they were not comfortable
addressing spirituality, and responded that they were not sure when it was
appropriate to introduce issues of spirituality (Souza, 2002). These findings
should not be surprising, given that orily 25% of counselor educators surveyed reported that their training program provided for courses addressing
spiritual concerns in counseling and despite a recognition and support for
incorporating spirituality in counseling (Kelly, 1995).

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Evidence from previous survey research with counselor participants suggests that some counselors paid little attention to the importance that the
spiritual beliefs of their clients might have on the therapeutic process, thus
raising the question of whether the client's agenda or the counselor's was
more important in the therapeutic relationship (Gubi, 2004). One explanation for mental health professionals' reluctance to address spirituality in
counseling is their own lack of comfort in addressing issues of spirituality
(Bartoli, 2003; Shafranske, 1996).

Clients' Perceptions of Spirituality in Counseling

'.

The professional literature on research regarding clients' perceptions of using


spirituality in counseling is in its infancy (Guine & Tracey, 1997; McClure
& Livingston, 2000; Zinnbauer & Pargament, 2000). The research on clients'
perceptions that has emerged in the professional literature to date has largely
focused on potential clients (prospective clients not currently seeking or receiving counseling) rather than actual clients (Worthington et al., 1996). Rose,
Westefeld, and Ansley (2001) explored clients' preferences for discussion of
spiritual issues as well as clients' beliefs about the appropriateness of spiritual
discussion in psychotherapy. The results of their study indicate that many clients believe that spiritual issues are acceptable and preferable for discussion in
therapy and are important therapeutic factors (Rose et al., 2001). The findings
of the Rose et al. study are consistent with those of previous research suggesting that religion is relevant to counseling for some individuals (Dougherty &
Worthington, 1982; Misumi, 1993; Wyatt & Johnson, 1990).
Potential clients may have concerns about how therapists respond to their
spiritual beliefs, and these concerns may have an impact on clients' willingness to discuss spiritual issues. Quackenbos, Privette, and Klentz (1985)
reported that prospective clients are concerned that counselors might seek
to modify a client's religious beliefs either by undermining those beliefs or
by attempting to convert the clieint to the therapist's own religion. Miovic
(2004) concurred in stating that counselors who are atheistic or agnostic
should be wary of demeaning theistic clients and should understand that
theistic clients may limit their emotional involvement in therapy in order
to guard themselves against the negative judgments of skeptical therapists.
Yet, Rose et al. (2001) found only a minority of clients who reported that
their willingness to discuss religious or spiritual issues depended on how
the counselor might respond to them.

Research Purpose and Questions

..

The purpose of this survey study was to examine the perceptions of clients
and counselors regarding the role of spirituality in the counseling context.
This study expands the current research literature by exploring the perceptions of both clients and counselors within the same community and in the

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same period of time. This is the first known study to investigate both the
perceptions of clients receiving counsehng in a Christian practice and the
perceptions of clients receiving counseling in a secular practice. To this end,
the following research questions were addressed:
1. To what degree do counseling professionals perceive spirituality to
be acceptable, effective, and important relative to their theoretical orientation as a component for helping clients achieve their goals in the
counseling context?
2. To what degree do counseling professionals self-report using spirituality as an intervention tool in the counseling context?
3. To what degree do chents report spirituality being incorporated into
their counseling sessions (and in what form)?
4. Do clients report wanting spirituality to be incorporated to a greater
or lesser degree in their counseling sessions?
5. Do chents perceive spirituahty to help, hinder, or have no effect on
their progress in counseling?

Method
Settings and Participants
Counseling professionals. The sample of counseling professionals consisted
of individuals who were providing counseling/psychotherapy services to
children and adults in a midwestern city of approximately 166,000 residents.
A total of 34 professionals responded to the questionnaire among the 75
professionals initially recruited for participation. Therefore, the response
rate was 45.3%. The selection and contact information for these counseling
professionals were obtained from graduate students enrolled in a community
counseling program at a local university who were completing their internship. Thus, the counseling professionals represent a convenience sample of
professionals who all have interns placed in their practice.
The respondents included counselors, social workers, psychologists, and
psychology and counselor trainees. Six of the professionals (17.6%) had a
bachelor's degree as their highest degree earned, 25 (73.5%) had a master's
degree, and 3 (8.8%) had a doctoral degree. (Percentages do not equal
100% because of rounding.) The number of years of experience practicing
counseling ranged from 0 to 32, with an average of 12 years. The majority
of the respondents (61.8%) had 6 or more years of experience providing
counseling. Fourteen (41.2%) of the professionals reported participating in
training in the use of spirituality in counseling, and 9 of these professionals
reported attending more than one class and/or seminar on the topic.
Clients. The clients participating in this study were receiving services from
two independently owned counseling practices located in the same midwestern city of approximately 166,000 residents. The clients were recruited
by their counselor, who followed a written script for presenting the purpose

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of the study and the clients' rights as participants of a research study. No


incentive was offered to the participants.
A total of 73 clients responded to the questionnaire among the 75 clients
recruited for the study. The overall response rate was 97.3%. Among the respondents, 60.3% received counseling from the Ghristian counseling practice and
39.7% received services from the secular practice. The average age of the client
respondents was 40.5 years {SD = 12.1), and the ages ranged from 18 to 63 years.
Female clients represented the larger proportion of the sample (78.9%). When
asked to specify their race/ethnicity, 94.2% identified themselves as Caucasian,
4.3% identified themselves as African American, and 1.4% identified themselves
as Hispanic. (Percentages do not equal 100% because of rounding.)

Procedure
Survey of professionals. Counseling professionals were recruited in writing,
and informed consent was sought from each participant. The professionals
were informed that their participation was voluntary and that their responses
to the questionnaire would remain anonymous and confidential. A selfaddressed stamped envelope was provided along with the questionnaire
and the directions for returning the completed questiormaire.
Survey of clients. Clients who were 18 years or older were recruited by their
counselors to complete an anonymous questionnaire. The counselors were
trained in the manner in which the purpose of the study and the questionnaire were to be presented. Informed consent was sought from each client
participating in this study. If the client chose to participate, he or she completed the questionnaire in the waiting room of the private practice. The
completed questionnaires were kept in the box in the reception area until
the designated deadline to preserve the confidentiality of the participants.

Measures and Analysis


The following instrumentation was used to assess the research questions.
Professional Perceptions on Spirituality in Counseling Questionnaire (PPSCQ).

The PPSCQ is composed of three open-ended items in which participants


are asked to provide professional background information (e.g., training
in the use of spirituality), followed by three 5-point categorical rating
scale items (e.g., "To what degree do you view spirituality to be an effective intervention in counseling?"), and one 8-point categorical rating scale
item. This final item, requiring participants to self-rate their level of use of
spirituality as an intervention in counseling, was adapted from the Level
of Use Model developed by Hall and Hord (1987). The eight levels of use
are nonuse, orientation, preparation, mechanical use, routine, refinement,
integration, and renewal. Each level of use is operationally defined on the
PPSCQ, which can be obtained from the first author. This questionnaire
was developed for the purposes of this study based on the current research

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literature. The technical adequacy (i.e., reliability, validity) of the questionnaire has not been formally assessed. The three 5-point rating scale items
were developed to yield data in response to the first research question. The
8-point rating scale item was designed to provide data in response to the
second research question. Descriptive statistics were used to analyze the
results of this questionnaire.
Experiences in Counseling Questionnaire (ECQ). The ECQ was composed of 18
multiple-choice items and 1 open-ended item in which clients were asked to
provide demographic information. This questiormaire (available from the first
author) was developed for the purposes of this study based on the current
research literature. Three counseling professionals provided an independent
review of the ECQ prior to its being used for data collection. Descriptive
statistics were used to summarize the results of this questiormaire, and a
chi-square analysis was conducted to determine if there were statistically
significant differences in the responses of clients from the Christian practice
and from the secular practice.

Resuits
Research Question 1
To what degree do counseling professionals perceive spirituality to be acceptable, effective,
and important relative to their theoretical orientation as a component for helping clients
achieve their goals in the counseling context?

Counseling professionals participating in this study largely viewed incorporating spirituality as a component in counseling to be acceptable, effective, and
important relative to their theoretical orientation. On a 5-point rating scale,
where 1 was very acceptable and 5 was unacceptable, the item yielded a mean
of 1.65 {SD = 0.73). The degree to which the counselor judged spirituality to
be an effective intervention was measured on a 5-point rating scale, where 1
was very effective and 5 was ineffective. This item yielded a mean of 1.74 {SD
= 0.71). The importance of spirituality relative to the counselor's theoretical
orientation was measured on a 5-point scale, where 1 was very important and
5 was unimportant. This item yielded a mean of 2.06 {SD - 1.13).

Research Question 2
To what degree do counseling professionals self-report using spirituality as an intervention tool in the counseling context?

In response to a question regarding professionals' level of use in implementing spirituality in counseling, the practitioners' responses ranged from 0
{nonuse) to 7 {renewal). Nearly a fourth of the professionals (23.5%) assessed
their level of use as 0 {nonuse), and 50.0% rated their use as 5 {refinement)
or higher. The mean level of use was 3.65 {SD = 2.62), placing the average
level of use between 3 {mechanical use) and 4 {routine).

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Research Question 3
To what degree do clients report spirituality being incorporated into their counseling
sessions (and in what form)?

Overall, 68.5% of the clients from both practices responded that spirituality
had been included during counseling with their current counselors. Clients
in the Christian practice differed from the clients in the secular practice in the
percentage who reported the use of spirituality in their counseling session,
and this difference was statistically significant {x^- 31.26, p = .00). Among
the clients recruited from the Christian practice, 93.2% indicated spirituality had been included in their counseling sessions and that counselors were
largely responsible for introducing spirituality. Only 31.0% of the clients
from the secular practice reported that spirituality had been included in their
counseling session. In these instances, the client was most often responsible
for introducing spirituality in counseling.
The clients were also asked to report the types of activities used by
counselors and clients to incorporate spirituality into counseling. A high
percentage of clients reported that "talking about spirituality" was initiated
by the counselor (85.7%) and by the client (85.7%). In contrast, few clients
reported that praying aloud was counselor initiated (4.1%) or client initiated
(2.0%). Similarly, few to no clients, reported that praying silently was initiated by the counselor (0.0%) or client (4.1%). Reading from the Bible was
more frequently initiated by the counselor (14.3%) than by the client (2.0%).
Reading from another religious bdok was also more frequently initiated by
the counselor (18.4%) than by the cHent (10.2%). Furthermore, reading from
an inspirational book was initiated by the counselor (46.9%) more often than
by the client (10.2%).

Research Question 4
Do clients report wanting spirituality to be incorporated to a greater or lesser degree in
their counseling sessions?

Among the 50 clients (41 clients from the Christian practice, 9 clients from
the secular practice) who received counseling with a spirituality corhponent, 16.7% reported that they would like spirituality to be included in
their counseling sessions more often, 72.9% indicated they would like
spirituality to be included in their counseling sessions at the same level,
4.2% responded that they would like spirituality to be included in their
counseling sessions less often, and 6.3% of these clients reported that they
did not have a preference. (Percentages do not equal 100% because of
rounding.) Comparisons between the responses of clients from the Christian
practice and from the secular practice were not possible, given the limited
number of clients from the secular practice who reported that spirituality
was used in counseling.
'

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Research Question 5
Do clients perceive spirituality to help, hinder, or have no effect on their progress in
counseling?

Among the clients from both practices who experienced having a spirituality component in their counseling sessions, 73.5% reported it had been very
helpful in making progress toward their counseling goals, 16.3% reported it
had beet) moderately helpful, and 10.2% reported it had been neither helpful nor unhelpful. None of the clients indicated a spirituality component in
their counseling session had been unhelpful.

Discussion
The purpose of this survey research was to examine the perceptions of
counseling professionals and clients regarding the role of spirituality in the
counseling context. In contrast to previous research, the majority of counseling
professionals in this study reported that introducing spirituality in counseling was acceptable, effective, and important to their theoretical orientation to
counseling. Despite these generally positive perceptions of the acceptability,
effectiveness, and importance of incorporating spirituality in counseling,
these same professionals were divided in their report of their use of spirituality as a counseling intervention. The finding that half of the participants in
this study were implementing spirituality as a counseling intervention at the
three highest levels (refinement, integration, and renewal) differs from the
results of previous research that has indicated that spirituality is accepted as
an important tool theoretically, yet mental health professionals are not using
it in actual practice (Gubi, 2004; La Torre, 2002; Miovic, 2004). Given that the
majority of the counseling professionals were not new to the field, this finding
of an increase in the use of spirituality as an intervention is less likely due to
changes in graduate trairiing programs and more likely due to individuals'
professional development initiatives in response to trends and needs within
the field. It is interesting that the number of professionals reporting high levels of use exceeded the number of professionals that reported participating
in a class or seminar on the use of spirituality in counseling. Future research
might explore less formal ways counselors develop their professional skills in
this area and contrast their outcomes with professionals who received formal
trairng in the use of spirituality in counseling. In addition, future research
should explore how counselors reach their decision to incorporate a spirituality
component in the counseling process and whether their approach to practice
has changed in this regard over the course of their professional practice. This
future line of research should also include examining counselors' perceptions
of spirituality in relation to their own religious orientation.
Clients' report of the use of spirituality in the counseling process varied
considerably by the type of pracfice from which they were recruited, with a
greater percentage of clients from a Christian practice, compared with clients

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. from a secular practice, reporting that the counseling they received involved a
spirituality component. Given the varied definitions of spirituality, the
multiple-choice format used in this study may have restricted what was considered spirituality in counseling, with an emphasis on church practices. Although
the aspects of spirituality in counseling were perceived as helpful by the majority of clients, future research should explore the full range of how spirituality
could be incorporated in the counseling process (e.g., existential issues, identity
matters, end-of-life concerns) from the perspective of the client.
The tentative implications of this study include the need for a thorough
assessment of each individual client and his or her spiritual mindedness
needs prior to introducing a spiritual component in the counseling context.
Presenting clients with the opportunity to have spirituality incorporated
in counseling enables the client to make an informed decision regarding
whether spiritual matters should be included.

Limitations and Suggestions for Future Research


The results of this study should be viewed with caution in light of several
limitations inherent in this study. First, the degree to which the counseling
professionals participating in this study are representative of the larger population of counseling professionals is highly questionable, given that this was
a convenience sample of relatively small size. The counseling professionals
recruited for this study all worked in counseling practices that supported
an intern from a community counseling program at a local university. The
perceptions of counseling professionals in practices that were not selected as
internship sites remain unknown. Furthermore, although the results of the
survey may accurately reflect the perceptions of counseling professionals who
agreed to participate in the study, we know nothing about the perceptions
of counseling professionals who chose not to respond to the survey. Future
research should use a larger and more representative sample of professionals
obtained through the membership rosters of one or more professional organizations. The results obtained from the survey of clients should also be viewed
as tentative given the modest sample size and the predominance of clients
recruited from a Christian counseling practice. A final limitation of this study
concerns the possibility of bias in the questionnaire completed by counseling
professionals because of the sequencing of items. Items regarding the amount
of professional training and the professionals' perceptions of the acceptability,
effectiveness, and importance of spirituality in counseling preceded respondents' self-rating of their level of use. The degree to which these earlier items
might have biased the professional's response to the level-of-use item cannot
be determined. Future research should place the level-of-use item earlier in
the questiormaire and consider seeking a second source of data (e.g., client's
report, observation) to verify the accuracy of the self-rating. Future research
should also explore differences in counselors' perceptions of the acceptability,
effectiveness, and importance of spirituality in counseling, particularly in relation to their own religious orientation and definition of spirituality.

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Conclusion
Despite these limitations, this study makes a modest contribution to a topic
that continues to ignite dialogue. Trends in the United States suggest that the
role of spirituality in the personal and public lives of its citizens has risen
in recent years. Counseling professionals need to challenge themselves continually to address the issues most relevant to the daily lives of their clients.
The results of this study suggest that counseling professionals may be using
spirituality in the counseling context to a greater degree than has previously
been reported. Clients in this study vary in whether they are interested in
having spirituality included in their counseling process, suggesting that a
thorough individual assessment should be conducted by the counseling
professional before spirituality is introduced in counseling.

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