COUNSELOR SPIRITUAL COMPETENCIES: AN EXAMINATION OF COUNSELOR PRACTICES Except where reference is made to the work of others, the work described in this dissertation is my own or was done in collaboration with my advisory committee. This dissertation does not does not include proprietary or classified information. ___________________________________ Keith Aaron Cates Certificate of Approval: ______________________________ John C. Dagley Associate Professor Special Education, Rehabilitation, Counseling/School Psychology _____________________________ Chippewa M. Thomas Assistant Professor Special Education, Rehabilitation, Counseling/School Psychology ______________________________ Suhyun P. Suh, Chair Associate Professor Special Education, Rehabilitation, Counseling/School Psychology ______________________________ George T. Flowers Dean Graduate School COUNSELOR SPIRITUAL COMPETENCIES: AN EXAMINATION OF COUNSELOR PRACTICES Keith Aaron Cates A Dissertation Submitted to the Graduate Faculty of Auburn University in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Auburn, Alabama August 10, 2009 iii COUNSELOR SPIRITUAL COMPETENCIES: AN EXAMINATION OF COUNSELOR PRACTICES Keith Aaron Cates Permission is granted to Auburn University to make copies of this dissertation at its discretion, upon request of individuals or institutions and at their expense. The author reserves all publication rights. ______________________________ Signature of Author ______________________________ Date of Graduation iv DISSERTATION ABSTRACT COUNSELOR SPIRITUAL COMPETENCIES: AN EXAMINATION OF COUNSELOR PRACTICES Keith Aaron Cates Doctor of Philosophy, August 10, 2009 (B.F.A., University of West Georgia, 1991) (B.A., University of West Georgia, 1991) (M.A., University of West Georgia, 1997) (Ed.S., University of West Georgia, , 2005) 147 Typed Pages Directed by Suhyun Suh The purpose of this study was to investigate the spiritual competencies and practices used by mental health professionals, particularly the 1) knowledge, 2) awareness, 3) understanding, and 4) interventions these practitioners employ in regard to religious and spiritual aspects of client issues, how these practices correspond with the ASERVIC spiritual competencies and how these practices differ across a) the participant?s professional identity (i.e., a counseling professional or psychological professional), b) years of professional experience, c) age, d) gender, e) racial/ethnic affiliation, f) level of academic achievement, and g) religious affiliation. Ninety-four counseling and psychology professionals responded to a quantitative survey answering 34 questions. The survey was presented to licensed clinicians and sought the clinicians? v perceptions of their own use of knowledge, awareness, understanding, and interventions related to religious and spiritual issues encountered in clinical practice. The survey questions were subjected to reliability assessment, univariate and multivariate analysis of variance, and post hoc analysis to examine the differences of perceptions of counseling and psychology professionals. Significant differences were found between affiliations of counseling and psychology professionals. Significant differences were also found between selected demographic groups in both the spiritual competency domains and the spiritual competencies. vi ACKNOWLEDGEMENTS This dissertation is dedicated to Valerie, Ashur and Cian who were my unwavering motivation and support as well as to countless others who supported, encouraged and mentored me through the graduate and doctoral process. I would like to thank Dr. Suhyun Suh, my advisor and committee chair, who has guided through this process and whose patience and support were instrumental in its completion. Additional appreciation is given to Dr. Chippewa Thomas, Dr. John Dagley, Dr. Kathryn Jarvis, Dr. Daniel Henry and Dr. Margaret Ross for their feedback, critical review and sage advice in developing this research concept and subsequent dissertation. Finally, I would like to thank all my friends in the counselor education program and Academic Support Services at Auburn University, and specifically Michael Keim and Mark Parrish who made this process memorable. vii Style manual used: Publication Manual of the American Psychological Association, 2001 (5 th ed.) Computer software used: Microsoft Office Word 2007; Statistical Product for Social Sciences (SPSS) 17.0. viii TABLE OF CONTENTS LIST OF TABLES ..................................................................................................... xi I. INTRODUCTION ......................................................................................... 1 Purpose ........................................................................................................... 5 Significance of the Study ............................................................................... 7 Research Questions ........................................................................................ 8 Operational Definitions .................................................................................. 8 Summary ........................................................................................................ 10 II. LITERATURE REVIEW .............................................................................. 12 Religion vs. Spirituality ................................................................................. 12 Religion .............................................................................................. 14 Spirituality.......................................................................................... 16 Benefits of Religious and Spiritual Involvement ........................................... 18 Religion and Spirituality within a Multicultural Context .............................. 20 Spirituality in Counselor Training and Practice ............................................. 24 Spirituality in Mental Health ............................................................. 24 Spirituality in Counselor Training ..................................................... 28 Spirituality in Counselor Practice ...................................................... 32 Religion and Spirituality in the Therapeutic Process ..................................... 33 Positives of Including Awareness of Religion and Spirituality in Counselor Practice ............................................................................. 34 Negatives of Excluding Religion and Spirituality in Counselor Practice ............................................................................................... 35 Integration of Religious and Spiritual Awareness into the Therapy Process ................................................................................. 36 Development of Spiritual Competencies in Counseling ................................ 38 Influence of Multicultural Competencies .......................................... 38 Spiritual Competencies in Professional Mental Health Organization Standards ...................................................................... 40 ASERVIC Spiritual Competencies .................................................... 41 ix III. DESIGN and METHODOLOGY .................................................................. 46 Purpose ........................................................................................................... 46 Research Questions ........................................................................................ 47 Participants ..................................................................................................... 47 Procedure ....................................................................................................... 48 Survey Instrument .......................................................................................... 50 Data Analysis ................................................................................................. 51 Summary ........................................................................................................ 51 IV. RESULTS ...................................................................................................... 53 Characteristics of Participants ........................................................................ 54 Reliabilities .................................................................................................... 56 Results of Competency Analyses ................................................................... 63 Research Question 1 .......................................................................... 63 Research Question 2 .......................................................................... 64 Research Question 3 .......................................................................... 65 Research Question 4 .......................................................................... 69 Age ..................................................................................................... 69 Gender ................................................................................................ 73 Years of Professional Experience ...................................................... 76 Racial/Ethnic Affiliation .................................................................... 78 Academic Achievement ..................................................................... 81 V. DISCUSSION ................................................................................................ 83 Discussion of the Findings ............................................................................. 85 Research Question 1 .......................................................................... 85 Research Question 2 .......................................................................... 87 Research Question 3 .......................................................................... 89 Research Question 4 .......................................................................... 91 Limitations ..................................................................................................... 94 Implications.................................................................................................... 96 Counselor Education .......................................................................... 96 Counseling Practice ........................................................................... 97 Research ............................................................................................. 98 Summary ........................................................................................................ 99 REFERENCES .......................................................................................................... 101 APPENDICES ........................................................................................................... 117 Appendix A: Spiritual Competency Survey Recruitment Letter ................. 118 x Appendix B: Spiritual Competency Survey Instructions and Survey Consent .................................................................................. 119 Appendix C: Spiritual Competency Survey ................................................ 121 Appendix D: Counselor Spiritual Competencies ......................................... 127 Appendix E: Thematic Code of Counselor Spiritual Competencies ........... 128 xi LIST OF TABLES Table 1 Demographic Description ..................................................................... 55 Table 2 Reliability Analyses for Spiritual Competency Questionnaire ? Domains ................................................................................................ 59 Table 3 Reliability Analysis for Spiritual Competency Questionnaire ? Competencies ........................................................................................ 61 Table 4 Competencies Domain by Professional Affiliation .............................. 66 Table 5 Competency by Professional Affiliation ............................................... 66 Table 6 Univariate Comparison of Domains by Professional Affiliation .......... 68 Table 7 Univariate Comparison of Competencies by Group ............................. 68 Table 8 Competencies Domain by Age Analysis .............................................. 70 Table 9 Competency by Age Analysis ............................................................... 71 Table 10 Univariate Comparison of Domains by Age ......................................... 72 Table 11 Univariate Comparison of Competencies by Age ................................ 72 Table 12 Competencies Domain by Gender Analysis ......................................... 74 Table 13 Competency by Gender Analysis.......................................................... 74 Table 14 Univariate Comparison of Spiritual Competencies Domains by Gender ................................................................................................... 75 Table 15 Univariate Comparison of Spiritual Competencies by Gender ............. 75 Table 16 Competencies Domain by Years of Professional Experience Analysis 77 Table 17 Competency by Years of Professional Experience Analysis ................ 77 Table 18 Competencies Domain by Racial/Ethnic Affiliation Analysis ............. 79 xii Table 19 Competency by Racial/Ethnic Affiliation Analysis .............................. 79 Table 20 Univariate Comparison of Competencies by Racial/Ethnic Affiliation .............................................................................................. 81 Table 21 Competencies Domain by Level of Academic Achievement Analysis 82 Table 22 Competency by Level of Academic Achievement Analysis ................ 82 Table 23 Survey Questions According to Domain .............................................. 132 1 I. INTRODUCTION The importance of spirituality and religion in American culture is clear. Recent surveys show that 93% of the American population stated they believed in God or a universal spirit, 56% stated that religion was very important in their lives, over 41% have attended church, synagogue, or temple within the past 7 days (?Religion by Gallup Poll News Service,? 2008), and 23% of those who attended church or temple at least monthly went primarily for spiritual growth and guidance (Newport, 2007). Many Americans consider spirituality and religion to be core areas of their lives (Burke et al., 1999; Pate & Bondi, 1992), others describe spirituality as an important source of strength and direction in their lives (McLennan, Rochow, & Arthur, 2001) and more than two thirds of Americans consider personal spiritual practices to be an important part of their daily lives (Hoge, 1996). While more than 76% of Americans claim either a Protestant or Catholic religious affiliation (Kosmin, Mayer, & Keysar, 2001), there are still many people who engage in some form of spiritual practice that does not include organized religion, a deity or a higher power (Cashwell & Young, 2005). For many, spiritual and religious affiliation is a "more potent social glue than the color of one's skin, cultural heritage, or gender" (Shafranske & Malony, 1996, p. 564) and in any form religious and spiritual beliefs are vital components of the individual's culture, values, and world-view (Bishop, 1992; McLennan et al., 2001; Pate & Bondi, 1992; Richards & Bergin, 2000b) 2 In the 2001 American Religious Identification Survey (ARIS) (Kosmin et al., 2001) more than 76% of Americans claimed a Christian religious affiliation while Richards and Bergin (2000a) found that over 160 denominations, most of them Christian, and more than 700 non-Christian groups (e.g., Jews, Muslims, Buddhists, Hindus) existed in the United States. With this breadth of diversity in organized religious groups, mental health professionals will be expected to work with increasingly diverse client populations with a broad range of spiritual and religious backgrounds (Richards & Bergin, 2000b). Many views of spirituality are nebulously defined and allow for the inclusion of higher powers which can aid in the development of personal wholeness and meaning. Others are more closely linked to the structures of religion which provide a foundation for spirituality and make it personally meaningful. With such broad definitions of spirituality it can be easily seen that the profession of counseling needs to be responsive to the various religious and spiritual perspectives that will be presented to counselors in clinical practice (2000b). The United States is experiencing a population growth due largely to immigration that rivals the great immigration from Europe during the early part of the 20th century (Cushner, McClelland, & Safford, 2005). This growth is leading to a greater diversity in our population and a better understanding of the place of religion and spirituality in a person?s worldview is necessary in order to understand the increasing diverse needs of our society (Buttery & Roberson, 2005). Diversity is no longer seen as just an awareness of the differences between people. It has grown to include the respect and understanding of the diverse cultural 3 values and religious and spiritual beliefs of the client for whatever reason prompted them to seek counseling (D?Andrea & Daniels, 2005). The inclusive nature of multiculturalism requires that we strive to understand the needs of these populations in their totality of cultural, religious, and political dimensions (Arredondo et al., 1996). This understanding is not only a demonstration of cultural sensitivity and respect for our clients (McLennan et al., 2001), but our ethical obligation (D'Andrea & Daniels, 2005, January; Richards & Bergin, 2000b). This acceptance of diversity in spiritual orientation is necessary in a society that is home to members of all of the world?s major religions (Richards & Bergin, 2000b) and was founded on the ideal of freedom of religion. With nearly one-quarter of the American population (23.5%) not affiliated with Christian religious groups (Kosmin et al., 2001) counselors will be interacting with more diverse populations than ever before as religious diversity increases due to an ?increased level of education, world-consciousness, and individualism and immigration? (Hoge, 1996, p. 38). This interaction would likely include those non-mainstream spirituality populations that hold Unitarian Universalist, Pagan, Spiritualist, and Native American spiritual beliefs as well as immigrants to the United States who bring spiritual beliefs unique to their cultural and ethnic backgrounds. This could also include those people who hold agnostic, atheistic or alternative spiritual beliefs that have no correspondence with mainstream American religious practices. This range of religious and spiritual practices brought to counseling sessions by clients can be as varied as the people using them, and they don?t necessarily correspond with the background and training of the practitioners (Clark, 2002; D'Andrea & Sprenger, 2007; 4 Hodge, 2005; Khalid, 2006; Levitt & Balkin, 2003; McLennan et al., 2001). Therefore it is necessary for counselors to understand how their own religious and spiritual culture may differ from that of the general populace and the clients whom they serve (Walker, Gorsuch, & Tan, 2004). The influence of religion and spirituality on American culture makes it important for counselors to consider the role that religious and spiritual values play in the development of a client's attitudes and behavior. Spirituality is often a significant part of the issues a client brings to counseling, such as those concerns involving personal and social relationships, and personal growth and development, and is a valid and essential part of holistic approaches to counseling (McLennan et al., 2001). In times of crisis people often turn to religious and spiritual resources for support and guidance (Worthington, 1989). And, when faced with stressful issues, research shows that clients would prefer to see a counselor who is sensitive to spiritual issues and who holds similar spiritual values and beliefs (Burke et al., 1999; McLennan et al., 2001). In 1995 Kelly found that 81% of people surveyed reported that they preferred a counselor who could address spirituality within the counseling process and counselors with spiritual beliefs and values were preferred by clients with serious problems. This supported a survey conducted by Quackenbos, Privette and Klentz (1985) where 79% of their participants thought that religious beliefs were important to address in counseling, and also supports Hendlins (1989) findings that clients? religious orientations were found to be significant in selecting a counselor, suggesting that some clients look specifically at the spiritual and religious orientation of a potential counselor (Belaire & Young, 2000). 5 Spirituality is not only a significant and integral part of human experience, but spirituality is also an integral part of human development (Bishop, Avila-Juarbe, & Thumme, 2003) and needs to be recognized and validated in the client's experience. To ignore the spiritual aspects of a person?s life and worldview may be to neglect a fundamental part of the client's identity and life (Burke et al., 1999; McLennan et al., 2001; Miller, 1999; Wiggins-Frame, 2003; Young, Wiggins-Frame, & Cashwell, 2007). Purpose Although a majority of the American population reports that religious and spiritual issues are very important in their lives (?Religion by Gallup Poll News Service,? 2008), it is only in the last 15 years that the professional associations have formally acknowledged religion and spirituality and integrated spiritual components into their ethical guidelines (American Counseling Association, 2005; American Psychological Association, 2002; Canadian Psychological Association, 2000). In 1997, the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) developed what has been spiritual competency guidelines for counselors (Miller, 1999). Following this have been continuing attempts to concisely define spirituality (Chandler, Holden, & Kolander, 1992; Clark, 2002; Jankowski, 2002; Speck, 2005) in order to codify standards against which to measure counselor competency (Gordon & Mitchell, 2004; McLennan et al., 2001). There has also been increased attention given to how to incorporate those competencies into counselor training courses and program curriculums as well as the work of individual counselors. The primary area of investigation has been focused on the current state of counselor 6 training programs and the inclusion of the ASERVIC spiritual competencies in coursework, training and counselor supervision (Cashwell & Young, 2004; Young, Cashwell, Wiggins-Frame, & Belaire, 2002) and only one survey (Young et al., 2007) has looked at the counselors? view of the spiritual competencies and their individual readiness and capacity to use them. Research studies have reported that there is minimal preparation in spiritual and religious diversity and interventions in clinical training programs from both American Counseling Association (ACA) and American Psychological Association (APA) based programs (Brawer, Handal, Fabricatore, Roberts, & Wajda-Johnston, 2002; Hage, Hopson, Siegel, Payton, & Defanti, 2006; Shafranske & Malony, 1996). While among faculty and counseling professionals there is receptivity to classroom discussions, research on religious and spiritual issues, and willingness to supervise students on these issues, there is also a lack of competence in counseling clients and in supervising students on issues related to spiritual or religious concerns. Results from studies involving master's-level counselor education suggest that Council for Accreditation of Counseling and Related Educational Programs (CACREP) accredited programs are more adequately equipped to provide spiritual and religious diversity training (Pate & High, 1995; Young et al., 2002). That they appear relatively more suitably prepared may reflect the CACREP standards that reinforce the significance of training in spiritual and religious aspects of counseling (CACREP, 2001; CACREP, 2008; Hage et al., 2006). To further explore these findings this study investigated the extent of inclusion of spiritual knowledge, awareness, and skills in mental health professionals? clinical 7 practices. The value of this study is in examining how practitioners, particularly counseling and psychological professionals, are currently working with spiritual and/or religious issues, how these practices correspond with the ASERVIC spiritual competencies and how these professionals compare with each other in their exercise of spiritual competencies across demographic variables. Significance of the Study At a time when many Americans consider spirituality and religion to be core areas of their lives (Burke et al., 1999; Pate & Bondi, 1992) an examination of how counselors are currently working with spiritual and/or religious issues may serve to illuminate to what extent spiritual competency is being utilized and expressed in counselor practice. The significance of this study is in its exploration of counselor practices as they relate to clinician understanding of the influence religion/spirituality can have on individual and cultural identity; their awareness of their own religious and spiritual perspectives, biases and directions for growth; their understanding of a client?s needs and awareness in regards to religious/spiritual issues; and their ability to develop and utilize religious and spiritually appropriate interventions in the counseling process. Through a focus on counselor practices we may be able to better understand to what extent clinicians are currently using spiritual competencies in their practices, how these practices correspond with the ASERVIC spiritual competencies and how these practices differ across demographic variables. This understanding may further the development of the spiritual competencies and lead to identification of clinical behaviors that best exemplify spiritually competent practices. 8 Research Questions 1) What spiritual knowledge, awareness, understanding, and interventions do counseling professionals exercise in their counseling practice? 2) What spiritual knowledge, awareness, understanding, and interventions do psychology professionals exercise in their counseling practice? 3) How do counseling and psychology professionals differ in their spiritual knowledge, awareness, understanding, and interventions in clinical practice? 4) How do counseling and psychology professionals differ in their spiritual awareness, understanding, knowledge, and interventions skills based on their demographic characteristics? Operational Definitions Awareness of their own religious and spiritual perspectives: The self-awareness and exploration of the counselor?s religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of their own religious and/or spiritual belief system. It also includes a counselor?s understanding of their own biases and directions for growth, and the capacity to explain various models of religious/spiritual development across the life span. Counseling Professional: An individual with a master?s degree or higher whose highest degree attained is from a counseling or related program. This person primarily follows the standards of practice and ethical guidelines as outlined by the American Counseling Association and is state licensed to practice as a mental health professional. 9 Interventions and strategies utilizing religious and spiritual approaches: The assessment of the relevance of the spiritual domains in the client?s therapeutic issues and the use of a client?s spiritual beliefs in the pursuit of therapeutic goals as befits the client?s expressed preferences. This includes the application of religiously and spiritually appropriate interventions in the counseling process as well as an understanding on the part of the counselor as to the limits of their understanding of a client?s spiritual expressions and the application of appropriate referral knowledge and skills. Knowledge of spiritual phenomena: An ability to explain the relationship between religion and spirituality, including similarities and differences, and to describe religious and spiritual beliefs and practices within a cultural context. Psychology Professional: An individual with a master?s degree or higher whose highest degree attained is from a psychology based program. This person primarily follows the standards of practice and ethical guidelines as outlined by the American Psychological Association and is state licensed to practice as a mental health professional. Religion: A set of beliefs concerning the cause, nature, and purpose of the universe, especially when considered as the creation of a superhuman agency or agencies, usually involving devotional and ritual observances, and often containing a moral code governing the conduct of human affairs. Spiritual Competencies: The awareness, practices and skills accepted as necessary for the integration of faith and spirituality into counseling as developed by the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC). 10 Spirituality: A person?s individual beliefs, awareness, values, subjective experience, sense of purpose and mission, and/or a search for wholeness and harmony which may or may not include a deity. Understanding of client?s needs and awareness in regards to religious/spiritual issues: A demonstrated sensitivity to and acceptance of a variety of religious and/or spiritual expressions in a client?s communication, as well as a sensitivity and respectfulness of the spiritual themes in the counseling process as befits each client?s expressed preferences. Summary Although the majority of Americans consider religious and spiritual aspects of their lives to be very important, counseling and psychological professionals have rarely been trained how to integrate these aspects into their clinical practice. To better serve their clients counselors must develop a broad understanding of not only the needs of adherents of diverse religious practices but how to use these diverse practices and perspectives to foster growth in their clients. An exploration of clinicians? practices in regards to religious and spiritual knowledge, awareness, understanding and interventions and how these correspond with the ASERVIC spiritual competencies will help us to better understand how practitioners are currently working with and integrating spiritual and religious issues into clinical practice. The purpose of this study was to investigate the spiritual competencies and practices used by counseling and psychology professionals in the domains of 1) their knowledge of religious and spiritual phenomena, 2) the mental health professionals? awareness of their own spiritual perspectives, 3) their understanding 11 of clients? religious and spiritual perspectives, and 4) the religious and spiritually related interventions and strategies these practitioners employ. 12 II. LITERATURE REVIEW Religion vs. Spirituality Historically, spirituality was not distinguished from religiousness until the rise of secularism in this century (Turner, Lukoff, Barnhouse, & Lu, 1996), and a popular disillusionment with religious institutions as a hindrance to personal experiences of the sacred (Zinnbauer et al., 1997). With this decline of institutional forms of religion noninstitutional and nontraditional forms of spirituality grew to fill the void (Marler & Hadaway, 2002). With this rise of individual spirituality came the complexity of explaining the differences between religion and spirituality, and it is important to distinguish between them as each generally describes separate aspects of individual experience. Although spirituality and religiousness have been defined in many ways, ?religiousness? generally refers to an adherence to the beliefs and practices of an organized church or religious institution (Hinterkopf, 1994; Shafranske & Malony, 1990; Stanard, Sandhu, & Painter, 2000). It represents substantive, extrinsic expressions that are distinct and public (Marler & Hadaway, 2002; Pargament, 1999). ?Spirituality?, in contrast, is considered to be any experience that transcends a person?s former frame of reference and brings new meanings to their perceptions (Chandler et al., 1992; Hinterkopf, 1994) and represents the personal, affective, experiential, functional, and 13 more intrinsic dimensions of religion (Marler & Hadaway, 2002; Richards & Bergin, 1997). While religiousness historically included both individual and institutional elements it is now commonly described as formally structured and identified with religious institutions and prescribed theology and rituals (Zinnbauer et al., 1997). Spirituality has stepped in to take the place of many of the historical relevance of religion and is regarded as an individual phenomenon and identified with such things as personal transcendence, supraconscious sensitivity, and meaningfulness (Spilka and McIntosh, 1996 as cited in Zinnbauer et al., 1997). Spirituality may be positively related to specific forms of religiousness but is not necessarily reliant on any given form or appearance of religion (Hinterkopf, 1994). Many people experience spirituality outside the context of organized religion (Ingersoll, 1994) and involvement with the social institutions of religion is only one aspect of spirituality (McLennan et al., 2001). Legere (1984) approached this conceptual co-relationship in this way: ?Spirituality has to do with experience; religion has to do with the conceptualization of that experience. Spirituality focuses on what happens in the heart; religion tries to codify and capture that experience in a system? (p. 376). But this doesn?t diminish the difficulty some people have conceptualizing spirituality outside of organized religion, whereas others cannot imagine spirituality within the defining structure of a religious setting (Porter, 1995). Some are uneasy at the thought of participating in formal religion, while others have difficulty trying to separate their 14 spirituality from their religion as they feel that the two of them are intertwined (Curtis & Glass, 2002). The differentiation of religion and spirituality is an important issue as the differences between religion and spirituality can mark a boundary between what is considered an acceptable affirmation of a transcendent connection to the universe on the one hand (spirituality), and generally unacceptable ritual and doctrinal behaviors associated with religions and denominations on the other (Bergin & Jensen, 1990; Kelly, 1992; Shafranske & Malony, 1990). A counselor who ignores the transformative aspects of spirituality in favor of the extrinsic expressions or religion (i.e., spiritual traditions, beliefs, and ritual practices) may fail their client in their transformative journey (i.e., through spiritual practices and experiences). Similarly, the counselor who focuses only on the transformative capacity of spiritual experience may not be able to assist the client who is ?searching for meaning in life, the translative aspect of spirituality? (Cashwell & Young, 2005, p. 3). Religion Religion has been defined as the logical outcome and organized attempt to give a framework to the sense of awe for the transcendent (Fukuyama & Sevig, 1997; Helminiak, 2001; Pate & Bondi, 1992). Religion also tells its adherents what life is about and how one is to live that life (Helminiak, 2001). In one sense, religion is an institutional and primarily material phenomenon. While spirituality is often at the center of their interests and goals, religions are social entities and institutions, and unlike spirituality, they are defined by their boundaries. 15 They provide their members with the specific organized and codified forms through which they may express their spirituality (Miller, 1999). Religions are differentiated by particular beliefs, practices, creeds, doctrines, requirements of membership, and modes of social organization (Richards & Bergin, 2005). What is spiritual or transcendent may be a primary focus, but religions are also characterized by other non-spiritual concerns and goals (e.g., cultural, economic, political, social). Religion can be seen as fundamentally a social structure, whereas spirituality (like health and personality) is usually understood at the level of the individual (Thoresen, 1998 as cited in Miller & Thoresen, 2003). Viewed in this way, ?the field of religion is to spirituality as the field of medicine is to health? (Miller & Thoresen, 2003, p. 28). In another sense religion is a social phenomenon and a person?s religion (or religiousness) can be conceptualized at the level of the individual (James, 1994). A person can be described (or can describe herself or himself) as being religious, which implies some adherence to a particular set of religious beliefs, practices, or doctrine. Within this view it is possible to conceptualize private as well as public forms of religiousness and the potential overlap with spirituality becomes clearer. Religiousness is defined in relation to religion, but spirituality at the level of the person may or may not be based in religion (Miller & Thoresen, 2003). Religion may be a form of spirituality for some people as they experience their spirituality through rituals and doctrine of organized religion, but the two concepts of religion and spirituality are not mutually exclusive (Wiggins-Frame, 2005). It is also the case with some people that their involvement with a particular religion is more or less a 16 social interaction. These people may participate in organized religion out of a sense of obligation, habit, social and cultural pressures, or fear of consequences for not participating. These people, while not pursuing the spiritual aspects of their religious involvement and therefore not being considered spiritual, could certainly be considered religious (Miller & Thoresen, 2003; Wiggins-Frame, 2003). Spirituality At the turn of the twentieth century William James (1994) regarded religion as the ?feelings, acts, experiences of individual men [sic] in their solitude ? in relation to whatever they may consider the divine? (p. 42). Since then spirituality has grown to include such concepts as transcendence, self-actualization, purpose and meaning, wholeness, balance, sacredness, altruism, universality, and a sense of a Higher Power (Stanard et al., 2000). The counseling literature provides many definitions for the term ?spiritual? and views it as universal, spontaneous, and private (McLennan et al., 2001) and ?those experiences, beliefs, and phenomena that pertain to the transcendent and existential aspects of life? (Richards & Bergin, 2000b, p. 5). Other definitions include ?the individual's search for meaning and value in life? (Fukuyama & Sevig, 1997, p. 233) or ?a view of one's place in the universe? (Pate & Bondi, 1992, p. 108). It is considered by some to be the quality of being concerned with the life-giving force/animating principle (e.g., God, Spirit, True Nature, True Self, Source) (Marra, 2000). More recently, spirituality has been defined as personal beliefs that transcend the material aspects of existence and produce a sense of connectedness to the infinite (Myers, Sweeney, & Witmer, 2000; Myers & Williard, 2003; Witmer & Sweeney, 1992). 17 Common threads have been found among studies that have attempted to define the experience of spirituality. According to Hinterkopf (1994) the spiritual experience may be defined as (a) a presently felt phenomenon, (b) involving an awareness of the transcendent dimension, (c) bringing new meanings, (d) that lead to growth. Briggs and Rayle (2005) used a previously conceptualized four-theme model of spirituality (Briggs, Apple, & Aydlett, 2004) to describe common elements of spirituality relevant for clients of all backgrounds. These themes of spirituality included engaging in events or relationships that promote a sense of personal worth, using an internal orientation for guidance, maintaining deep connections with the self, others, nature and the cosmos, and having a healthy sense of relatedness to self, others, and all life. Ellison (1983) asserted that it is the spirituality of human beings that motivates and inspires them to search for meaning and purpose in life, while Clark (2002) defined authentic spirituality as an emotional response that can include feelings of significance, unity, awe, joy, acceptance, and consolation. Elkins, Hedstrom, Hughes, Leaf, and Saunders (1988) found through a review of the literature that spiritual values inspire purposefulness and meaning in life, a sense of the sacredness of life, an attention to the spiritual rather than the material, an altruistic attitude toward others, a vision for the betterment of the world, and an awareness of the tragic and painful, and perhaps above all, found that it also means living out these values with discernible effects on oneself, others, and nature and on one's relationship with a higher power (Maher & Hunt, 1993; Stanard et al., 2000). 18 In 1995, in an effort to define spirituality an encompassing definition was put forth by the Summit on Spirituality, an event endorsed by the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC): [T]he animating force in life, represented by such images as breath, wind, vigor, and courage. Spirituality is the infusion and drawing out of spirit in one's life. It is experienced as an active and passive process. Spirituality also is described as a capacity and tendency that is innate and unique to all persons. This spiritual tendency moves the individual towards knowledge, love, meaning, hope, transcendence, connectedness, and compassion. Spirituality includes one's capacity for creativity, growth, and the development of a values system. Spirituality encompasses the religious, spiritual, and transpersonal. (?Summit results in information of spirituality competencies,? 1995, December, p. 30) Benefits of Religious and Spiritual Involvement In recent years the concept of health as just a disease-free biological condition has given way to a concept of wellness as a healthy balance of the mind-body and spirit that results in an overall feeling of well-being. More and more health is viewed as a holistic process influenced by emotional, mental, cultural, social, and philosophical factors, including the existence of meaning and purpose in life and the quality of intimate personal relationships (Holmes, 1998; Maher & Hunt, 1993; Ryff & Singer, 1998). Investigations into defining an optimal spectrum of health (Chandler et al., 1992; Witmer & Sweeney, 1992) have placed spirituality at the core of wellness and numerous articles 19 and books have recently been written suggesting the efficacy of incorporating spirituality in medicine (Curlin et al., 2007; Curtis & Glass, 2002; Koenig & Cohen, 2006) and the positive impact of spirituality or religious practices on individual health (Bishop et al., 2003; Kelly, 1995; Richards & Bergin, 2000b). Research suggests that religious and spiritual endeavors (i.e., yoga, prayer, meditation, and church attendance) have been positively correlated to increased academic performance in students (Glanville, Sikkink, & Hern?ndez, 2008), can increase clients? chances of recovery, have been found to be an important factor in a patient?s ability to cope with serious and chronic illnesses (Ehman, Ott, Short, Ciampa, & Hansen-Flaschen, 1999; Koenig & Cohen, 2006; Miller & Thoresen, 2003) can relieve stress, moderate anxiety and lower blood pressure, and have been linked to increased longevity ("Spiritual Matters, Earthly Benefits," 2001, August). Religious resources are prominent among the methods that people use when coping with life-stress and illness (Pargament & Ano, 2006) with many (43.0%) specifically using prayer in an attempt to support their own health (Barnes, Powell- Griner, Fann, & Nahin, 2004). A majority of patients receiving health care say that they would like their caregivers to ask about and discuss spiritual aspects of their illness, with particularly high percentages among patients who regularly attend religious services (Ehman et al., 1999; Miller & Thoresen, 2003) Pargament (2002a) has supported the idea that when faith is internalized it provides meaning in life and fosters well-being. He indicated that even the controversial religions seem to have advantages. For instance, research has indicated that fundamentalism correlated both with greater prejudice toward those different from 20 oneself and with increases in well-being. It also seems that socially marginalized groups, more religiously committed people, and those experiencing very stressful situations (i.e., death) found more benefit in religion than did others (Weld & Eriksen, 2007). A concern when investigating the benefits of religious and spiritual interactions on health is the reduction of religion to an oversimplified form of social-religious practices (Kelly, 1995). This runs the risk of denying the benefits that many people gain from their involvement with organized religion, precisely because it incorporates creedal, institutional, and ritual elements (Kelly, 1992; Pargament, 2002b). Secularly based counselors and therapists, being more scientifically-based than their religiously-based counterparts, may have concerns working with the structures of formalized religious beliefs and practices (Kelly, 1992). To ensure that they do not disregard the positive involvement that many people have with traditional religions and religious practices counselors need to educate themselves about spiritual issues in a number of ways including familiarizing themselves with research, and continuing education and training so as to appreciate the healthy potentialities of religious involvement (Genia, 1994, 2000). Religion and Spirituality within a Multicultural Context ?Religion, spirituality and culture are intertwined and interrelated. Religion and spirituality exist within cultures, and it is likely that few cultures exist without some expressions of religion and spirituality? (Fukuyama, Siahpoush, & Sevig, 2005, p. 123). The religious beliefs of clients must be considered equally with cultural values if diversity among clients is to be respected (Pate & Bondi, 1992). The prevalence of 21 religious and spiritual focus in people?s lives combined with the growing diversity of populations that counselors are called upon to interact with (Clark, 2002; D'Andrea & Sprenger, 2007; Hodge, 2006 ; Hoge, 1996; Khalid, 2006; Levitt & Balkin, 2003) that a multicultural perspective that includes spiritual and religious issues needs to be further investigated to determine how it can be incorporated into therapy and counseling services. Bergin (1991) stated, "Psychologists' understanding and support of cultural diversity has been exemplary with respect to race, gender, and ethnicity but the profession's tolerance and empathy has not adequately reached the religious client" (p. 399). Much of the literature that addresses client-counselor similarity in the context of ethnicity, race, and culture could also be applied to the issues of religion or spirituality (Powers, 2005; Sue, Arredondo, & McDavis, 1992). Spirituality is another area of individual difference, diversity, and multiculturalism that needs to be addressed as such (Richards & Bergin, 2000a; Stanard et al., 2000) as an individual's experience of spirituality or religious practice is intricately intertwined with ethnic and cultural experience (Bishop et al., 2003). Spirituality is an integral part of many people's racial and cultural identity, shaping their worldview and sense of self (Hage et al., 2006) and culture must be understood to encompass the "totality of a person's identity comprised by historical moments, unchangeable human factors and a range of developmental, socio- cultural, political and economic dimensions including religion" (Arredondo et al., 1996, p. 31). 22 Pedersen (1999) asserted that the multicultural perspective is a forceful influence in mental health counseling and takes a broad view of culture: ?Ethnographic variables such as ethnicity, nationality, religion, and language, as well as demographic variables such as age, gender, and place of residence, [and] status variables such as social, economic, and educational factors, and affiliations.? (p. 93). Likewise, Coughlin (1992) reported that social scientists are showing increased interest in cultural diversity and ethnicity, and "religion is understood to be intimately tied to ethnic identity" (p. 6). He felt that more social scientists and mental health professionals must consider the role a person's religious or spiritual values play in personality or mental health, because personality, attitudes, and behavior are shaped by these cultural values. There has also been an increasing recognition that the values and practices of religious clients deserve the same level of respect and sensitivity as any other ethno- cultural aspect of a client's life (Bergin, Payne, & Richards, 1996; Fukuyama & Sevig, 1999). The concept that religion and spirituality are relevant to clinical practice and are as much a part of a person's orientation to life as their ethnicity and gender and culture is becoming a standard within the therapeutic community (Eck & Moon, 2002). Religious beliefs are an aspect of culture that must be considered in the service of diverse populations. As competent multicultural counseling is based on respect for and appreciation of the uniqueness of each individual, counseling must recognize that multicultural awareness includes all aspects of culturally, ethnically, racially, and religiously diverse populations (Pate & Bondi, 1992). 23 Pate and Bondi (1992) supported the concerns raised by Locke (1990) that to view multicultural counseling simply as recognition of the individual differences of clients is to deny that people are both individuals and members of groups. They suggested that all members of a culture, both ethnic minority group members and majority group members, bring meaningful differences in their religious beliefs and values to counseling. Those differences are in some instances related to group membership and in others are related to individual experiences. Similarly Vontress and Jackson (2004) cautioned against stereotyping clients on the basis of cultural generalizations as it can lead to a perception of the client as strictly a product of a generalized cultural view and limit the understanding of their uniqueness as individuals. Pate and Bondi (1992) asserted that the counselor must accept that part of the cultural development of many of their clients has involved religion, and to omit that aspect of their clients' lives from counseling is to potentially omit a significant part of their client?s identity and worldview. With the range of religious, spiritual and cultural possibilities in the world the counselor must also accept that they may encounter clients who have atheistic beliefs (D'Andrea & Sprenger, 2007), naturalistic spirituality and humanistic beliefs that don?t depend on faith in higher powers (Clark, 2002). Counselors must accept the fact that, for clients who lack a belief in a higher power, believe there is no God, or have limited or no spirituality, their experience is also real, valid, and significant for them (D'Andrea & Sprenger, 2007). 24 Acceptance of diversity for counselors, then, is not just the acknowledgement of those who are different from us in cultural, religious and spiritual outlooks. It is a an understanding and respect of their potentially diverse beliefs and the need that brought them to counseling to work through adversity, pain, loss, and other psychological stressors, including marginalization that are obstacles to their growth. Multiculturalism, in the context of counseling, addresses the need for counselors and counselors-in-training to promote social justice by empowering clients who belong to groups that have traditionally been outside the mainstream perceptions of our society (D'Andrea & Daniels, 2005, January). The challenge is to balance respect for religious diversity with a sense of spirituality that evokes an appreciation of common, life-enhancing themes, without allowing religious dogma to become a rationalization for unethical and dehumanizing behavior (Burke et al., 1999). Spirituality in Counselor Training and Practice Spirituality in Mental Health Traditionally psychologists were trained and expected to focus primarily on the psychological dimension, while leaving the spiritual dimension to the clergy and other spiritually minded individuals. To date, few mental health practitioners have received formal training in working with spiritual and religious issues in counseling (Burke et al., 1999; Genia, 1994; Schulte, Skinner, & Claiborn, 2002; Shafranske & Malony, 1990; Shafranske & Malony, 1996; Wiggins-Frame, 2003; Young et al., 2007) and although clinical psychologists generally viewed spiritual and religious issues as being relevant to their clinical work, only a third of respondents expressed having personal competence in 25 counseling clients in matters of spirituality. Shafranske and Malony (1996) also found that 85% of clinical psychologists reported the frequency of discussion of psychology and religion in their training to be rare or never. Brawer, Handal, Fabricatore, Roberts and Wajda-Johnston?s (2002) survey of 98 directors of clinical training at APA-accredited clinical programs echoed the experience of the clinical psychologists surveyed by Shafranske and Malony (1996). When looking at how spirituality and religion were incorporated into training programs, including course work, supervision, and training, Brawer et al. found that only 17% of directors reported covering the content systematically, and 16% of directors indicated that their programs did not cover these issues at all. Today therapists are expected to be aware of and sensitive to spiritual, religious, ethical, and moral issues, as well as to incorporate the spiritual into their professional work as many clients are insisting that therapists deal with both the spiritual and the psychological. This has left many therapists looking for ways to incorporate the spiritual into their practice without compromising the scientific basis of their disciplines. In order to address this need Sperry (2001) offered a theory-based, clinically focused text that integrated a broad range of theoretical perspectives and clinical strategies for understanding and intervening with the spiritual, moral, and religious issues that emerge in therapy. He presented multiple perspectives and developmental models on the process of spiritual growth. Working from the premise that there are five basic dimensions of human experience: psychological, social, moral, somatic, and spiritual with the spiritual dimension central to and integrally related to the other four dimensions. He presented six 26 specific conceptualizations of the spiritual dimension: Character, Ethical, Transpersonal, Self-Transcendence, Object-Relations, and Conversion as they relate to the process of spiritual growth and development. Following the explanations of how a person can progress developmentally, Sperry (2001) presented strategies for incorporating the spiritual dimension into the counseling session. These range from assessment of the client?s religious/spiritual history to spiritual disciplines, practices and techniques that are appropriate for use in psychotherapy. In an effort to show a selection of the varying perspectives of spiritual approaches being used by psychotherapists Richards and Bergin (2004) compiled a book of case studies illustrating the application of multiple theistic approaches to counseling and psychotherapy. These case studies show the specific approaches of therapists who hold a view of the world in which a concept of god is central and their work with individuals of various backgrounds. It attempts to show the diversity in the idea of a god-centered approach to counseling as well as the responses of the clients as they work with various concerns including sexual orientation, alcoholism, depression and eating disorders. In an attempt to look directly at the way people?s self-perceptions of spirituality influence health related decisions Petry and Finkel (2004) sought to determine if a person?s score on a psychospiritual characteristic testing instrument is related to that person?s choice to integrate a complementary and alternative medicine practitioner into their personal health care. Their study suggested that people who chose an alternative medicine practitioner indeed scored higher on the psychospiritual testing instrument than those who chose a conventional physician. Another study by Belaire and Young (2000) 27 looked at how self-perceptions of spirituality might influence counselor selection among surveyed university students and found that their self-reported level of spirituality as determined by the Human Spirituality Scale had no significant effect on their choice of a counselor; however, results did show that a counselor described as competent in working with spiritual issues did influence some participants? preference for that counselor. Utilization of knowledge of the importance of spirituality and religion has prompted many investigations into spirituality as an aspect of therapy and awareness of spiritual and religious issues in counseling has been at the forefront of the relevant literature since the development of generally accepted spiritual competencies in 1997. However, conceptualizing and incorporating these newly recognized skills into counselor training and practice has been difficult. Hall, Dixon and Mauzey (2004) summarized Miller and Thoresen?s (2003) Spirituality, religion, and health: An emerging research field to illustrate the concerns of researching such a topic. They identified six areas of concern which included basic assumptions contributing to the sparsity of research dealing with spirituality, definitions of spirituality, religiousness and religion, levels of evidence for reviewing studies, and modeling approaches to statistical control. They suggested that quality research in spirituality could be accomplished if appropriate approaches to reviewing studies and models of statistical control were maintained, namely, determining and using parallel standards of evidence across reviews, and determining the unique amount of variance that is explained by religious variables in predicting a variety of dependent variables. They then suggested that further research should be conducted to 28 determine the function of spiritual and religious discussion and its practice in counseling (Hall et al., 2004). Spirituality in Counselor Training There is a growing awareness and willingness to explore spiritual and religious matters within the context of counseling and counselor preparation programs. Kelly's (1994) and Pate and High's (1995) surveys of counselor education programs found that counselor educators themselves have a generally positive attitude toward religion and spirituality as a legitimate aspect of counselor training despite modest attention to spiritual/religious issues in counselor education curricula (Burke et al., 1999). However, except for institutions that are church affiliated or programs that are of an explicitly religious nature, counselor education programs do not typically offer courses that address spirituality (Bishop et al., 2003; Fukuyama & Sevig, 1997). In 1994, Kelly conducted a national survey of 341 counselor education programs, where more than two thirds (n = 264) of the respondents were program heads at state- affiliated institutions. All regions of the Association for Counselor Education and Supervision were represented and the final sample contained more than 75% of the programs accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP) and the American Psychological Association (APA). Indeed, spirituality and religion seem to receive modest to mixed attention in counselor training as only 25% of 341 accredited and non-accredited counselor education programs reported that spirituality and religious issues were included as a course component (Young et al., 2007). In answer to the question; to what extent are religious and spiritual 29 issues dealt with in counselor education courses, non-course activities, and intern supervision? A majority of programs had no course (n = 287), no course component (n = 250), or no other learning activities (n = 167) dealing with religious-spiritual issues through counseling. Likewise, a majority of the programs provided little or no intern supervision on religious-spiritual issues related to either the client (n = 177) or the intern (n = 171). Fewer than half (n = 141, 45.3%) of counselor education program heads considered religion/spirituality as very important or important topics in counselor preparation, and only 128 (41.2%) considered them somewhat important. Responses to the other items regarding spiritual-religious issues indicated that applicants' religious motivations were not an item of interest or inquiry in the vast majority of counselor education programs, and religious-spiritual issues were perceived to have little or no negative effect on students' performance (Kelly, 1994). Pate and High?s 1995 study showed that 60% of CACREP programs included a consideration of religious beliefs and practices in their foundational studies, while Kelly?s (1997) analysis of 48 programs accredited only by CACREP (as distinguished from programs with dual or multiple accreditation) showed that 52% reported that spirituality and religion are included in some part of their counselor education curriculum, with 15% not including client religious issues as a part of their curriculum and not considering it important to do so (Kelly, 1997). Following Kelly?s 1994 survey Young et al. (2002) focused a national study on how spiritual and religious competencies influence program development. Young et al. surveyed 94 CACREP-accredited programs to determine which ones addressed spiritual 30 and religious issues. They found that 23 of the 94 CACREP-accredited counseling programs that were surveyed indicated that they offered a specific course on spirituality and religion in counseling, 69% reported course content that addressed spiritual issues and 78% of counselor education programs had no specific course that addressed spirituality and religion. They also found that only 46% of survey respondents perceived themselves as prepared to integrate spiritual and religious aspects into their teaching and supervision and that only 28% viewed their colleagues as similarly capable of addressing these issues as a component of counselor preparation. Young et al. also noted that no study to date had addressed counselor educator?s ability to train students to address spirituality issues and called for further research to examine specific course content in greater detail to determine what is actually taught in counseling programs in relation to spiritual and religious issues. In 2004, Cashwell and Young conducted a content analysis of 14 syllabi of introductory courses on spirituality in counseling. Content trends were examined to determine if they were consistent with the ASERVIC spiritual competencies. They found that there was substantial variance in the extent that course content and objectives follows the ASERVIC competencies and encouraged development of courses according to these competencies to achieve a unifying model for teaching spirituality. O?Connor (2004) continued the discussion on the limited literature of courses that are based on spiritual aspects by examining three courses designed to promote spiritual and religious awareness in students. He then introduced a description of an elective course he had taught that was based on integrating religion and spirituality into 31 counseling education. This course focused on expressions of spirituality and religion, both collective and individual, mediation techniques selected from various traditions, and a required weekly support group to supplement the academic portion of the course with personal experience. Overall the student evaluation of the course were very positive with most students appreciative of the opportunity to step out of their comfort zone and experience religious perspectives that may not otherwise have encountered. Feeling that spiritual beliefs were a major component of the fabric of life in many cultures and that the counseling field had overlooked their importance Fukuyama and Sevig (1997) developed their own course in spiritual awareness in counselor training to address these issues in order to fully prepare their students for clinical practice. Following the recommendations of Pate and Bondi (1992), the course integrated multicultural awareness with understanding variations in religious beliefs and perceptions of spirituality. It included didactic teaching on basic issues, such as assessment and ethical concerns, and experiential learning, so that students would have personal self-awareness from which to evaluate and understand client issues. The focus of the course was on adult development and spirituality, so counseling approaches were directed towards an adult population. Other techniques such as using case studies and using religious speakers as guest presenters were also incorporated. Student feedback was used to evaluate the effectiveness of the course and overall the course was regarded positively. It was felt that the students became more tolerant and understanding and came away with an appreciation of both the universality of spirituality and the culturally specific expressions of it (through religion). 32 Bishop et al. (2003), in a search across multiple databases, textbooks on spirituality and textbooks on counseling supervision, found that the literature regarding spirituality and the supervision process was very limited. While there is considerable literature on spirituality in counseling there is little consideration of these issues in the counselor training supervision process. Kelly?s 1994 survey of the role of religion and spirituality in counselor education supported this finding as the extent of attention to clients' and supervisees' religious and spiritual issues is also low (Kelly, 1994). These findings are consistent with findings for psychologist and psychiatrist preparation programs (Sansone, Khatain, & Rodenhauser, 1990; Shafranske & Malony, 1990). Spirituality in Counseling Practice To better understand the therapists? integration of religion and spirituality in counseling practice Walker et al., (2004) conducted a 26-study meta-analysis of 5,759 therapists and their integration of religion and spirituality in counseling. Across professions over 80% rarely discussed spiritual or religious issues in training and a therapists? religious faith was associated with using religious and spiritual techniques in counseling. They suggested further research should focus on therapist frequency and competency of use of spiritual techniques, rather than just determining if a therapist has used a particular technique. To begin to determine the competence of individual counselors in relation to spiritual competence Young et al. (2007) conducted a national survey of 505 American Counseling Association members to evaluate the perceived importance of the ASERVIC spiritual competencies. Overall, the survey participants supported the spiritual 33 competencies with 68% considering it important to receive formal training in addressing spiritual and religious issues; but only 47% had received coursework, 40% had attended workshops and 50% had read books and journal articles. Given this support, but lack of preparation, the authors highlighted a need to determine how practitioners are currently working with spiritual and/or religious issues and how they are advancing their training in these areas. Religion and Spirituality in the Therapeutic Process Although a historic split has existed between the religious and psychology since the turn of the century (Harper & Gill, 2005) with religious and spiritual issues being marginalized in the study and practice of psychology (Kelly, 1992), an examination of the two reveals that both work towards similar purposes, which is to help individuals find meaning, wholeness, and fulfillment (Mack, 1994). Traditionally psychologists were trained and expected to focus primarily on the psychological dimension, while leaving the spiritual dimension to the clergy and other spiritually minded individuals. Freud believed that psychotherapy should not involve values and lifestyle, particularly those of the counselor, and many influential authors have advocated the separation of religious and spiritual values from the practice of counseling (Hagedorn, 2005). But the profession of counseling has always had a grounding in a religiously and morally oriented social context, for example, in the works of Parsons (1967) and Davis (1914). Influenced by many factors including Carl Jung?s incorporation of religion and spirituality into analysis, Alfred Adler?s positive view of religion (Kelly, 1992), Abraham Maslow?s concept of self-actualization, which includes a spiritual dimension (Powers, 34 2005), and the growth of humanistic and existential therapies, the acceptance of spirituality and religion has expanded (Harper & Gill, 2005) to such an extent that many counselors are expected to be aware of, and sensitive to spiritual, religious, ethical, and moral issues, as well as to incorporate the spiritual into their professional work (Cashwell & Young, 2005). Positives of Including Awareness of Religion and Spirituality in Counselor Practice The primary reason for the inclusion of spiritual and religious awareness into counseling practice is that religion and spirituality are ?among the most important factors which structure human experience, beliefs, values, and behavior, as well as illness patterns? (Lukoff, Lu, & Turner, 1992, p. 673). In response to this, all helping professions appear to be moving toward a more holistic view of life and wellness that incorporates the spiritual into all aspects of the human experience (Mack, 1994; Myers & Truluck, 1998). This movement within both the general population and the profession of counseling will require counselors to become more competent in addressing clients' spiritual issues (Myers & Williard, 2003; Zinnbauer & Pargament, 2000). To support the inclusion of religion and spirituality in counseling Worthington (1989) found five reasons in the literature why counselors need to understand religious faith: a) The significance of religion and spirituality to the American population, b) People are more likely to turn to religion for help as situations become increasingly stressful, c) Clients may feel reluctant to bring up religious issues in secular counseling, d) Secular counselors are generally not as religiously oriented as their clients, and e) This lack of religious orientation by counselors may make it difficult to work with clients who 35 have religious or spiritual concerns. Supporting Worthington?s reasons Koenig and Pritchett (1998) indicated that addressing spiritual and religious issues with clients will help the therapist in several ways: (a) better understand the [client's] psychological conflict, (b) design interventions that are more acceptable to the [client] and congruent with their worldview (and thus more likely to be complied with), (c) identify healthy religious resources that may bring comfort and support, (d) recognize psychological roadblocks that prevent the [client] from utilizing potentially powerful spiritual resources, and (e) strengthen the therapeutic relationship (because this demonstrates sensitivity to an area that may be very meaningful to the [client]). (p. 327) Negatives of Excluding Religion and Spirituality in Counselor Practice A counselor may avoid discussion of spirituality in counseling for fear of imposing personal views on the client (Miller, 1999; Slife & Richards, 2001; Steen, Engels, & Thweatt, 2006; Zinnbauer & Pargament, 2000). But in doing this a counselor may inadvertently create barriers between themselves and their clients as clients may be suspicious of what they may consider an unfriendly environment that will discount, negate, or conflict with their religious values or spiritual worldview (Bishop et al., 2003). When counselors ignore a client?s religious or spiritual orientation, or accept spiritual and religious discussion but believe in only one form of expression of that spirituality may convey a message that religion is irrelevant to the client?s issues, and this may jeopardize the forming of an effective therapeutic relationship and close the door to potentially 36 pertinent intervention techniques (Burke et al., 1999; Steen et al., 2006). Research suggests that counselor beliefs that reflect a condemning view of higher powers and religious values can be potentially harmful to a client, while beliefs based in a supportive religious and/or spiritual model can be beneficial (Helminiak, 2001; Myers & Truluck, 1998; Steen et al., 2006; Zinnbauer & Pargament, 2000). Another concern of ignoring the spiritual and religious importance to clients is in the opinions that spiritual issues should be handled exclusively in the religious arena, namely by pastoral counselors and/or ordained clergy. Critics disagree with this and note that organized religion can create socially exclusive groups that act to isolate and individual within the religious structure (Schaef, 1992). This can act as a barrier to dialogue with those who don't share the values of that particular faith (Ingersoll, 1994) , and as Schaef (1992) noted, when helping professionals deny the potential existence of spiritual forces greater than the individual self, they fail to account for the power of values and ideas to affect the physical world of the client (Ingersoll, 1994). Integration of Religious and Spiritual Awareness into the Therapy Process In 1990 Bergin and Jensen surveyed 425 therapists representing 59% of a national sample of clinical psychologists, psychiatrists, clinical social workers, and marriage and family therapists. Of this national sample, 80% claim some type of religious preference, 77% agreed with the statement, "I try hard to live by my religious beliefs," and 46% agreed with the statement, "My whole approach to life is based on religion." Yet, only 41% attended religious services regularly and only 29% of them expressed a belief that religious matters were important in the treatment of all or many of their clients; in 37 contrast to the 80 to 90% of the general population who identify religion is important to them (Bergin & Jensen, 1990; Eck & Moon, 2002; Shafranske & Malony, 1990; Shafranske & Malony, 1996). A reason that there is such a discrepancy between the reported importance of religion and spirituality to both the general population and a large percentage of mental health professionals, and the relative silence in psychotherapy on the subject of religion may be due to bias in the profession against addressing religion in the therapy process (Eck & Moon, 2002). Therapists encourage clients to talk about their ethnic and cultural background, and their personal and family and emotional issues, but not their spiritual life (Eck & Moon, 2002). Bergin (1991) felt that the discrepancy ?probably reflects the fact that such matters have not been incorporated into clinical training as have other modern issues such as gender, ethnicity, and race" (p. 396). But it may also be difficult for clients to bring up religious issues due to fears of religious coercion and ridicule. Research reports that most clients want to talk about their spirituality (Kelly, 1995). Therapists should respect, honor and be sensitive to the boundaries that make religion a safe topic in therapy (Eck & Moon, 2002). As Worthington, Kurusu, McCullough, and Sandage (1996) stated ?Counselors?religious and nonreligious?must learn to evaluate and recognize their biases and competencies, so they can treat some religious clients effectively, refer religious clients whom they cannot treat effectively, and know the difference? (p. 479). 38 Development of Spiritual Competencies in Counseling In order to demonstrate cultural sensitivity and respect for their clients (McLennan et al., 2001) counselors have an ethical obligation to develop competencies in religious and spiritual diversity (Richards & Bergin, 2000a). And considering that America?s religious and spiritual diversity is continually changing counselors will need training to work competently and ethically with clients from various religious traditions (Bishop, 1992; Burke et al., 1999; Fukuyama & Sevig, 1997; Ingersoll, 1997). While the literature supports that religious and spiritual issues are within the scope of counselor practice, many counselors may not feel adequately prepared to assist individuals in their religious or spiritual development, especially since such topics are rarely discussed during their education (Shafranske & Malony, 1990). As Miller (1999) remarked about professional mental health training programs ?spirituality deserves neither more nor less attention than other important aspects of human nature ? to overlook or ignore [it] is to miss an important aspect of human motivation that influences personality, development, relationships, and mental health? (Miller, 1999, p. 261). By becoming educated about various religious and spiritual beliefs, increasing self- awareness, and learning to incorporate religion and spirituality into counseling, counselors can enhance their relationships with clients of diverse backgrounds (McLennan et al., 2001). Influence of Multicultural Competencies A multicultural perspective views religious and spiritual beliefs as important aspects of the client's culture (Pate & Bondi, 1992) and counselors need to be aware of 39 spiritual and religious concerns as a component of the client's values and worldview (Bishop, 1992; Fukuyama & Sevig, 1997; Pate & Bondi, 1992; Worthington, 1989). Worldview is seen as an individual's explanation for how and why reality behaves as it does with aspects of personal experience, including spiritual traditions in cultural and family environments, contributing to its construction (Lonborg & Bowen, 2004). In 1992, an article by Sue et al. on multicultural competencies included the terms religious and/or spiritual beliefs and values as viable cultural dimensions when discussing multiculturalism. This article laid the foundation for the development of the Multicultural Counseling Competencies and even though the counseling literature tends to separate multiculturalism and spirituality an understanding of spiritual processes has significant potential to contribute to multicultural understanding (Fukuyama & Sevig, 1999; Hage et al., 2006). Richards and Bergin (2000a) have noted that the skills and attitudes advanced by multicultural researchers such as Sue and Sue (1999) are conceptually similar to the skills and attitudes used by counselors when addressing religious and spiritual issues (Walker et al., 2004) and so the accepted multicultural competencies of a culturally skilled counselor may be similar to the capacities of a religiously and spiritually aware counselor (Hage et al., 2006). This view of the multicultural competencies support what has been stated in the literature, namely that religion or spirituality is an integral part of many people's racial and cultural identity, shaping their worldview and sense of self (Hage et al., 2006). The framework of the Multicultural Counseling Competencies (Sue et al., 1992) and the spirituality competencies (Miller, 1999) complement one another, in that each involves 40 examination of one's beliefs or attitudes, expanding one's knowledge, and developing counseling skills (Fukuyama & Sevig, 1999; Hage et al., 2006). Spiritual Competencies in Professional Mental Health Organization Standards Professional associations have formally acknowledged religion in their ethical guidelines as one aspect of cultural diversity that counselors need to consider (e.g., American Counseling Association, 2005; American Psychological Association, 2002; Canadian Psychological Association, 2000) and so mental health professionals have an ethical obligation to develop competencies in religious and spiritual diversity (Richards & Bergin, 2000a) in order to demonstrate cultural sensitivity and respect for their clients (McLennan et al., 2001). In the American Psychological Associations Ethical principles of psychologists and code of conduct (2002) it states that, ?Psychologists respect the dignity and worth of all people?including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups? (p. 4). Ethical practice as a psychologist recognizes the central role religion plays in a client's life and requires that the therapist demonstrate an awareness, sensitivity and respect for the client's religious beliefs, values and practices (Eck & Moon, 2002). Incorporating multicultural awareness into its own code of professional practice the ACA Code of Ethics (ACA, 2005, Preamble) states that ACA "members recognize diversity and embrace a cross-cultural approach in support of the worth, dignity, potential, and uniqueness of people with their social and cultural contexts." In addition, 41 "counselors actively attempt to understand the diverse cultural backgrounds of the clients they serve" and "explore their own cultural identities and how these affect their values and beliefs about the counseling process" (ACA, 2005, Section A), as well as recognize the effects ?age, color, culture, disability, ethnic group, gender, race, language preference, religion, spirituality, sexual orientation, and socioeconomic status? have on various aspects of the counseling process (ACA, 2005, Section E). ASERVIC Spiritual Competencies In 1995, in an attempt to give a voice to many of the calls for the inclusion of religion and spirituality the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) a division of the American Counseling Association (ACA) organized the first Summit on Spirituality. At this meeting, a set of nine spiritual competencies addressing four domains were developed: (a) knowledge of spiritual phenomena, (b) awareness of one's own spiritual perspective, (c) understanding clients' spiritual perspective, and (d) spiritually related interventions and strategies (Hage et al., 2006). These competencies were considered to be necessary for the ethical integration of religion and spirituality into counseling practice (Miller, 1999, p. 500). These competencies are: 1. A counselor should be able to explain the relationship between religion and spirituality, including similarities and differences. 2. A counselor should be able to describe religious and spiritual beliefs and practices within a cultural context. 42 3. A counselor should engage in self-exploration of his/her religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of his/her belief system. 4. A counselor should be able to describe his/her religious and/or spiritual belief system and explain various models of religious/spiritual development across the life span. 5. A counselor should demonstrate sensitivity to and acceptance of a variety of religious and/or spiritual expressions in the client?s communication. 6. A counselor should assess the relevance of the spiritual domains in the client?s therapeutic issues. 7. A counselor should be sensitive to and respectful of the spiritual themes in the counseling process as befits each client?s expressed preferences. 8. A counselor should use client?s spiritual beliefs in the pursuit of the client?s therapeutic goals as befits the client?s expressed preferences. 9. A counselor should identify the limits of his/her understanding of a client?s spiritual expression and demonstrate appropriate referral skills when necessary. The following descriptions of the ASERVIC spiritual competencies came from the works of recognized leaders in the field of spirituality and counselor education and practice. They were compiled by Cashwell and Young (2005) in the edited work Integrating spirituality and religion into counseling: A guide to competent practice. 43 In the first competency the professional counselor can explain the relationship between religion and spirituality, including similarities and differences. This competency differentiates between religion and spirituality with the understanding of the manifestation of either in a client?s life. It also promotes the clarification of the client?s perceptions of spirituality and religiousness (Wiggins-Frame, 2005). In the second competency the professional counselor can describe religious and spiritual beliefs and practices within a cultural context. They understand the role religion/spirituality can play in various cultures as well as the role religion/spirituality can have in cultural development and personal cultural identification. They attempt to develop an understanding of the potential interrelations between culture, religion, and spirituality and investigate culturally specific spiritual/religious issues that may include personal examination or consultation with religious leaders or cultural experts (Fukuyama et al., 2005). In the third the professional counselor engages in self-exploration of religious and spiritual beliefs in order to increase self-awareness, sensitivity, understanding, and acceptance of diverse belief system. They explore internal motivations, counter- transference issues and potential biases toward diverse spiritual and/or religious beliefs and practices attempt to develop an understanding of, or ongoing process of finding, one?s own religious/spiritual issues such as spiritual identity, spiritual worldview, and relationship with the world, God, or higher powers (Hagedorn, 2005; Helminiak, 2001). In the fourth the professional counselor can describe her/his religious and/or spiritual belief system and explain various models of religious/spiritual development 44 across the life span. They strive to develop an ability to explain the role of religion/spirituality in the counselors own life and worldview and how those views manifest in personal values and beliefs. They seek an understanding of how religious/spiritual beliefs can influence development and how religious/spiritual development can progress across a life time (Miller, 2005). In the fifth the professional counselor can demonstrate sensitivity and acceptance of a variety of religious and/or spiritual expressions in client communication. They encourage a client to be open about their religious and spiritual expressions and support the client?s experience and exploration of spirituality and religion through traditional spiritual/religious expressions (Briggs & Rayle, 2005). In the sixth competency the professional counselor can identify limits of her/his understanding of a client?s religious and/or spiritual expressions and demonstrate appropriate referral skills. They understand their own limits of knowledge, understanding and/or experience of the religious/spiritual needs of a client as well as their own biases and prejudices as regards diverse religious and spiritual orientations. They work to develop, and properly use when necessary, a knowledge of appropriate referral sources that are congruent with a client?s belief system (Faiver & Ingersoll, 2005). In the seventh the professional counselor can assess the relevance of the religious and/or spiritual domains in a client?s therapeutic issues. They explore a client?s values and spiritual and/or religious beliefs and the resources (emotional, spiritual, cognitive, etc.) that a client feels accompany these values and beliefs, and discuss the client?s perceptions of their own spirituality and/or religiousness with emphasis on the 45 importance of those perceptions in a client?s decision making or belief systems (Harper & Gill, 2005). In the eighth the professional counselor is sensitive to and respectful of religious and/or spiritual themes in the counseling process as befits the expressed preference of each client. They understand the place and importance of a client?s religious/spiritual values and beliefs, and the role of those beliefs and values in the creation or resolution of a client?s problems. The counselor explores the religious/spiritual beliefs of a client but refrains from introducing spiritual beliefs from outside a client?s expressed religious/spiritual orientation (Basham & O'Connor, 2005). In the ninth and final competency the professional counselor can use a client?s religious and/or spiritual beliefs in the pursuit of a client?s therapeutic goals as befits a client?s expressed preference. The counselor integrates into the counseling process the spiritual and religious components that are significant to a client and the counselor only uses spiritual and religious components and practices that are accepted within a client?s expressed religious/spiritual orientation (Basham & O'Connor, 2005). 46 III. DESIGN and METHODOLOGY Purpose Research studies have reported that there is minimal preparation in spiritual and religious diversity and interventions in clinical training programs from both ACA and APA based programs (Brawer et al., 2002; Hage et al., 2006; Shafranske & Malony, 1996). While among faculty and counseling professionals there is receptivity to classroom discussions, research on religious and spiritual issues, and willingness to supervise students on these issues, there is also a lack of measured competence in counseling clients and in supervising students on issues related to spiritual or religious concerns. Results from studies involving master's-level counselor education suggest that CACREP-accredited programs are more adequately equipped than non CACREP- accredited programs to provide spiritual and religious diversity training (Pate & High, 1995; Young et al., 2002). That they appear relatively more suitably prepared may reflect the CACREP standards that reinforce the significance of training in spiritual and religious aspects of counseling (Hage et al., 2006; CACREP 2001; CACREP, 2008). To further explore these findings this study investigated the extent of inclusion in counselor practice of knowledge of religious and spiritual phenomena and the influence religion/spirituality has on individual and cultural identity; the counselor?s awareness of their own religious and spiritual perspectives, biases and directions for growth; the counselor?s understanding of a client?s needs and awareness in regards to 47 religious/spiritual issues; and the counselor?s ability to utilize religious and spiritually appropriate interventions in the counseling process. The value of this study is in examining how counseling professionals are currently working with spiritual and/or religious issues, how these practices correspond with the ASERVIC spiritual competencies and how these practices differ across professional affiliation, age, gender and cultural affiliation. Research Questions 1) What spiritual knowledge, awareness, understanding, and interventions do counseling professionals exercise in their counseling practice? 2) What spiritual knowledge, awareness, understanding, and interventions do psychology professionals exercise in their counseling practice? 3) How do counseling and psychology professionals differ in their spiritual knowledge, awareness, understanding, and interventions in clinical practice? 4) How do counseling and psychology professionals differ in their spiritual awareness, understanding, knowledge, and interventions skills based on their demographic characteristics? Participants Participants in the study were counseling professionals who are self-identified as working in clinical, community or private practice in the state of Georgia. A counseling professional was considered to be an individual with a master?s degree or higher whose highest degree attained was from a counseling or related program. This person was licensed to practice in the state of Georgia as a mental health professional. 48 Participants were identified and contacted directly by the researcher via email and were provided with a link they could follow to a survey webpage that allowed them to participate in the study. To ensure adequate statistical power in the analysis of this study (Cohen, 1988) a minimum of 90 participants were surveyed. Procedure First, approval from the Auburn University Institutional Review Board (AU IRB) for the Use of Human Subjects in Research was obtained to conduct this study. Next, recruitment of study participants was purposeful, with targeted participants consisting of licensed mental health professionals. As the intent of this study was to investigate the practices and perceptions of mental health professionals, a purposeful sample was accessible through professional organizations (Creswell, 2007) provided the most appropriate sample population. A snowball sampling method was used that solicited social and professional networks of friends and acquaintances inviting them to participate in this study and asking them to pass along the informational email for this study to other potential participants. Invitations to participate in the study were also sent to contacts at various universities asking them to pass along the email to colleagues who might be interested. This snowballing method of recruitment was useful in that it determined potential study participants from those already involved in the study, or those with an interest in the study topic (Cherry, 2000; Miles & Huberman, 1994). Next, contact with the potential participants also occurred through the Licensed Professional Counselor?s Association of Georgia (LPCAGA) public access counselor locator database. Each potential participant was contacted to request their participation in 49 a survey designed to investigate counselor?s use of what they consider to be religious and/or spiritual knowledge, awareness, understanding and interventions in the therapy setting. The email sent to these individuals (Appendix A) provided brief descriptive information about the study and directed the potential study participant to a survey website page that contained information about the study, a description of the participant?s potential role, informed consent information, the benefits and risks of participation, and contact information related to potential inquiries (Appendix B). Those individuals desiring to continue with the study were directed to a link at the end of the consent information. Their consent to participate was shown by their clicking through the link to begin the survey. Participants were first asked to answer several demographic questions regarding their professional affiliation, cultural affiliation, age, gender, religious/spiritual affiliation, professional licensure status, academic degrees obtained, and experience as a counselor. If selection criteria were not met (i.e., a mental health professional licensed in the state of Georgia) the participant was taken to a webpage that thanked them for their interest and involvement in the study but stated that selection criteria had not been met for the purpose of the study. If participation criteria were met the participants were be taken to a webpage where they were asked questions to determine their views on integrating spiritual knowledge, awareness, understanding and interventions into counseling issues with their clients (Appendix C). When the participants completed the survey they were given a chance to review their answers before submitting the survey. They were able to withdraw 50 from the survey at any time during the course of the survey; however, as the survey was being conducted anonymously, once the participant?s survey answers had been submitted, they were not able to remove their responses from the collected data. Once the survey was submitted the participants were be taken to a page that thanked them for their interest and involvement in the study. Survey Instrument The survey (Appendix C) for this study was developed by the researcher based on a literature review of the ASERVIC spiritual competencies (Appendix D) and their use in clinical practice. The thematic code (Appendix E) and the questions used in the survey were developed from the literature describing the Knowledge, Awareness, Understanding, and Interventions that would best exemplify each spiritual competency as it could be utilized in clinical practice (Cashwell & Young, 2005). The survey consisted of 34 questions that reflected the clinical range of the competencies including assessment, self-awareness, client awareness, cultural awareness, therapeutic use of spiritual beliefs and the limits of clinical competence. The survey questions associated with each domain are shown in Table 23. The participants were asked to rate on a 5-point Likert-scale (1-strongly disagree / not at all, 2- disagree / disagree, 3-neutral, 4- agree / agree, and 5-strongly agree / very often) their interactions with clients regarding the inclusion of spiritual issues and awareness in clinical practice. Additionally, the survey collected demographic data including a) the participant?s professional identity (i.e., a counseling professional or 51 psychological professional), b) length of professional experience, c) age, d) gender, e) racial/ethnic affiliation, f) highest academic degree obtained and g) religious affiliation. To support face validity of this survey it was given to six counselors and psychologists to review. Their recommendations for clarity and ease of use by survey participants were incorporated into the survey in the form of revisions of the survey questions. Data Analysis The intention of this study was to investigate clinician perceptions and use of the constructs of Knowledge, Awareness, Understanding and Interventions in relation to the ASERVIC spiritual competencies. The research questions were subjected to an item analysis to determine the reliability of the survey questions. Univariate and multivariate (ANOVA and MANOVA) analysis of variance and Wilks? lambda analysis were used to compare the group means of the survey participant?s answers within the areas of their a) professional identity (i.e., a counseling professional or psychological professional), b) years of professional experience, c) age, d) gender, e) racial/ethnic affiliation, and f) level of academic achievement. A post-hoc analysis was performed on all variables whose difference in group means showed significance. Summary The research design and methodology chapter discussed the design and intention of the research study. Participant identification and selection were described as well as procedures for data collection from the sample population regarding clinical practices and 52 demographic data. The survey instrument was described as well as its basis in the literature relating to this field of study. This research study was not intended to be comprehensive in nature. As outlined in this chapter, this research study was intended to assess the practices of clinical mental health practitioners and their delivery of spiritually competent client care. 53 IV. RESULTS This chapter will present the results of the data analysis for this study. It includes the participant?s demographic information and the results of the statistical analysis. The purpose of this research study was to provide information regarding the spiritual competencies mental health practitioners employ in their clinical practice; particularly the extent of inclusion of spiritual knowledge, awareness, skills and interventions as they relate to the ASERVIC spiritual competencies. It also sought to investigate how the use of these competencies varied between counseling and psychology professionals and across demographic differences in the survey participants. It investigated the 4 domains of spiritual competencies and 9 individual spiritual competencies through the following research questions: 1) What spiritual knowledge, awareness, understanding, and interventions do counseling professionals exercise in their counseling practice? 2) What spiritual knowledge, awareness, understanding, and interventions do psychology professionals exercise in their counseling practice? 3) How do counseling and psychology professionals differ in their spiritual knowledge, awareness, understanding, and interventions in clinical practice? 4) How do counseling and psychology professionals differ in their spiritual awareness, understanding, knowledge, and interventions skills based on their demographic characteristics? 54 Characteristics of Participants Demographic information for this study was obtained from the participants of this study. They consisted of licensed professional counselors who were asked to identify themselves as either counselors or psychologists, each of whom is licensed in their respective fields. The demographic information collected includes: a) the professional affiliation of survey participants, b) years of experience working in their respective fields, c) age, d) gender, e) racial/ethnic affiliation, f) highest level of academic achievement, and g) religious affiliation. All 94 participants of this study completed the Demographic Questionnaire (Appendix C) and the demographic results are presented in Table 1. The participants in this study consisted of 72 counseling professionals and 22 psychology professionals. Of these professionals 18% have been working in their field for less than 5 years, 37% from 5 to 9 years, 27% from 10 to 14 years and 18% over 15 years. Fifty-six were female and 38 were male with the most common age being between 41 to 50 years old (31%), 31 to 40 years second (25%) and 51 to 60 years third (23%). Seventy-two percent of the survey participants identified as Caucasian with 12% African-American, 12% identifying as multiracial and 3% Hispanic. Seventy one percent (71%) of the survey participants possessed a Master?s degree in counseling or psychology, 5% had earned an Educational Specialist degree and 23% had attained a Doctorate in their respective fields. Of the survey participants 17% identified as Christian, 7% Baptist, 5% Catholic, 4% Protestant, 3% Methodist and 2% Jewish. The remaining survey participants identified with a wide variety of religious and spiritual doctrines and affiliations including Atheism, Buddhism, 55 earth-based spirituality, Gnostic, Goddess, Pagan and Wiccan. Due to the small sample sizes representing the various religious and spiritual groups no analyses were conducted focusing on religious affiliation. Table 1 Demographic Description Descriptor Variable Overall Counseling Psychology Professionals Professionals n (%) n (%) n (%) Professional 94 (100.0) 72 (76.6) 22 (23.4) Affiliation Years of 0 ? 4 yrs 17 (18.1) 15 (20.8) 2(9.1) Experience 5 ? 9 yrs 35 (37.2) 25 (34.7) 10 (45.5) 10 ? 14 yrs 25 (26.6) 19 (26.4) 6 (27.3) 15+ yrs 17 (18.1) 13 (18.1) 4 (18.2) Age of 21 ? 30 yrs 10 (10.6) 8 (11.1) 2 (9.1) Practitioner 31 ? 40 yrs 22 (23.4) 16 (22.2) 6 (27.3) 41 ? 50 yrs 31 (33.0) 20 (27.8) 11 (50.0) 51 ? 60 yrs 21 (22.3) 19 (26.4) 2 (9.1) 61+ yrs 10 (10.6) 9 (12.5) 1 (4.5) Gender Female 56 (59.6) 52 (72.2) 4 (18.2) Male 38 (40.4) 20 (27.8) 18 (81.8) Racial/Ethnic African- 11 (11.8) 8 (11.1) 3 (13.6) Affiliation American Table 1 continued 56 Descriptor Variable Overall Counseling Psychology Professionals Professionals n (%) n (%) n (%) Asian/ 0 (0.0) 0 (0.0) 0 (0.0) Pacific Islander Hispanic 3 (3.2) 2 (2.8) 1 (4.5) Multiracial 12 (12.8) 9 (12.5) 3 (13.6) Native 0 (0.0) 0 (0.0) 0 (0.0) American/ erican Indian/ Alaska Native/ First Nations White 68 (72.3) 53 (73.6) 15 (68.2) (Caucasian) Level of Doctorate 22 (23.4) 12 (16.7) 10 (45.5) Academic Achievement Educational 5 (5.3) 5 (6.9) 0 (0.0) Specialist Master?s 67 (71.3) 55 (76.4) 12 (54.5) (M.A./M.S./ M.S.W./ M.Div.) Reliabilities An item analysis using Cronbach?s Alpha reliability coefficient was used to determine consistency within the survey questions assigned to the 4 domains of spiritual competencies and 9 individual spiritual competencies. The 4 domains include: 57 1. Knowledge of spiritual phenomena: An ability to explain the relationship between religion and spirituality, including similarities and differences, and to describe religious and spiritual beliefs and practices within a cultural context. 2. Awareness of their own religious and spiritual perspectives: The self-awareness and exploration of the counselor?s religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of their own religious and/or spiritual belief system. It also includes a counselor?s understanding of their own biases and directions for growth, and the capacity to explain various models of religious/spiritual development across the life span. 3. Understanding of client?s needs and awareness in regards to religious/spiritual issues: A demonstrated sensitivity to and acceptance of a variety of religious and/or spiritual expressions in a client?s communication, as well as a sensitivity and respectfulness of the spiritual themes in the counseling process as befits each client?s expressed preferences. 4. Interventions and strategies utilizing religious and spiritual approaches: The assessment of the relevance of the spiritual domains in the client?s therapeutic issues and the use of a client?s spiritual beliefs in the pursuit of therapeutic goals as befits the client?s expressed preferences. This includes the application of religiously and spiritually appropriate interventions in the counseling process as well as an understanding on the part of the counselor as to the limits of their understanding of a client?s spiritual expressions and the application of appropriate referral knowledge and skills. 58 As well as how completely each group of questions measured the 9 spiritual competencies listed below: 1. Differentiation: A counselor should be able to explain the relationship between religion and spirituality, including similarities and differences. 2. Cultural Context: A counselor should be able to describe religious and spiritual beliefs and practices within a cultural context. 3. Self-Awareness: A counselor should engage in self-exploration of his/her religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of his/her belief system. 4. Development: A counselor should be able to describe his/her religious and/or spiritual belief system and explain various models of religious/spiritual development across the life span. 5. Acceptance: A counselor should demonstrate sensitivity to and acceptance of a variety of religious and/or spiritual expressions in the client?s communication. 6. Assessment: A counselor should assess the relevance of the spiritual domains in the client?s therapeutic issues. 7. Respect: A counselor should be sensitive to and respectful of the spiritual themes in the counseling process as befits each client?s expressed preferences. 8. Therapeutic Use of Beliefs: A counselor should use client?s spiritual beliefs in the pursuit of the client?s therapeutic goals as befits the client?s expressed preferences. 59 9. Limits of Understanding: A counselor should identify the limits of his/her understanding of a client?s spiritual expression and demonstrate appropriate referral skills when necessary. As shown in Table 2, reliability coefficients of each of the domain questions groupings ranged from a low of .896 (Awareness) to .898 (Understanding), to .927 (Knowledge) and finally to a high of .945 (Interventions). Among the competencies reliability (Table 3) coefficients varied from a low of .807 (Development) to a high of .906 (Therapeutic Use of Beliefs). Table 2 Reliability Analysis for Spiritual Competency Domains Domain Survey Number Mean SD Reliability Question # of Items Knowledge 1 8 3.98 .919 .927 2 4.08 1.024 3 4.01 .949 5 3.79 .863 6 3.95 .970 7 3.95 1.026 8 3.90 .989 15 3.91 .887 Awareness 9 7 4.14 1.121 .896 10 3.67 1.126 11 4.37 .890 Table 2 continued 60 Domain Survey Number Mean SD Reliability Question # of Items 12 4.26 1.073 13 4.04 1.010 14 4.42 .817 20 4.13 .872 Understanding 4 8 3.51 1.254 .898 16 4.47 .831 17 4.22 .936 18 4.32 .901 21 4.07 .875 27 4.38 .875 28 4.10 1.006 30 3.46 1.244 Interventions 19 11 3.96 .948 .945 22 3.57 .964 23 3.72 .930 24 3.58 1.251 25 3.52 1.200 26 3.60 1.158 29 3.59 1.169 Table 2 continued 61 Domain Survey Number Mean SD Reliability Question # of Items 31 3.71 1.305 32 3.61 1.301 33 3.64 1.289 34 3.53 1.208 Table 3 Reliability Analysis for Spiritual Competencies Competency Survey Number Mean SD Reliability (Thematic coding) Question # of Items 1 1 4 3.98 .914 .859 (Differentiation) 2 4.07 1.025 3 4.01 .943 4 3.52 1.262 2 5 4 3.78 .858 .848 (Cultural Context) 6 3.95 .971 7 3.95 1.015 8 3.89 .983 3 9 4 4.12 1.160 .870 (Self-Awareness) 10 3.65 1.148 11 4.34 .950 12 4.24 1.117 Table 3 continued 62 Competency Survey Number Mean SD Reliability (Thematic coding) Question # of Items 4 13 3 4.05 1.009 .807 (Development) 14 4.42 .815 15 3.91 .873 5 16 3 4.31 .897 .843 (Acceptance) 17 4.46 .828 18 4.22 .931 6 19 4 3.72 .932 .898 (Assessment) 20 3.60 1.247 21 3.52 1.189 22 3.61 1.157 7 23 4 4.39 .873 .841 (Respect) 24 4.10 1.001 25 3.59 1.163 26 3.45 1.238 8 27 4 3.70 1.300 .906 (Therapeutic Use of Beliefs) 28 3.60 1.295 29 3.65 1.282 30 3.53 1.203 9 31 4 3.96 .943 .814 (Limits of Understanding) 32 4.14 .880 Table 3 continued 63 Competency Survey Number Mean SD Reliability (Thematic coding) Question # of Items 33 4.05 .877 34 3.57 .960 Results of Competency Analyses Research Question 1: What spiritual knowledge, awareness, understanding, and interventions do counseling professionals exercise in their counseling practice? Research question 1 pertains to the components of spiritual competencies that counseling professionals use and may find essential for delivery of effective counseling practices with their clients. In this study counseling professionals showed that they use all four domains and all nine competencies in their clinical work. They reported that they frequently utilized, or valued as important, the domains of Knowledge, Awareness and Understanding with mean scores in this survey of 4.05, 4.25 and 4.23 respectively. The lowest scoring domain, Intervention, was used less often with an average usage of 3.88 (Table 4). In the application of the competencies, counseling professionals were consistent in their use with all of the competencies being employed in client interactions and personal development. Acceptance was the most favored among counseling professionals at 4.51 with Self ?Awareness, Development, Respect, Differentiation, Cultural Context and Limits of Understanding all reporting frequent use with scores of 4.26, 4.16, 4.08, 4.04, 4.0 and 4.0 respectively. Therapeutic Use of Beliefs and Assessment were used less often with scores of 3.97 and 3.84 (Table 4). 64 The range of survey answers from the counseling professionals were within one standard deviation across all four domains and all nine competencies. They varied from .664 (Understanding) to .777 (Awareness) for the domains and from .704 (Respect) to .831 (Assessment) for the individual competencies (Table 4). Research Question 2: What spiritual knowledge, awareness, understanding, and interventions do psychology professionals exercise in their counseling practice? Research question 2 reviews the components of spiritual competencies that psychology professionals use in their clinical approaches with clients. Overall, these professionals generally integrated their Awareness, Knowledge and Understanding of a client?s religious and spiritual issues into the counseling process reporting usage at 3.71, 3.61 and 3.5 respectively. The domain of Interventions was not used often with a score of 2.87. Standard deviations across the utilization of the spiritual domains varied considerably from .668 (Knowledge), .790 (Awareness), .799 (Understanding), to 1.097 (Interventions) (Table 4). Utilization of the spiritual competencies varied widely with Development being used most often (3.94) and most other competencies being used generally: Acceptance, 3.77; Limits of Understanding, 3.73; Cultural Context, 3.58; Self-Awareness, 3.51, Differentiation, 3.42; and Respect, 3.21. Two competencies, Assessment and Therapeutic Use of Beliefs, were rated as being infrequently utilized in practice with scores of 2.88 and 2.50 respectively. Standard deviations across the competencies varied more than the domains ranging from .636 (Limits of Understanding) to 1.391 (Therapeutic Use of Beliefs). The two largest standard deviations, 1.391 and 1.144, corresponded to the two 65 least used competencies, Therapeutic Use of Beliefs at 2.50 and Assessment at 2.88 (Table 4). Research Question 3: How do counseling and psychology professionals differ in their spiritual knowledge, awareness, understanding, and interventions in clinical practice? Table 4 shows the univariate analysis of variance (ANOVA) results of the participant perceptions of the four domains of Knowledge, Awareness, Understanding and Interventions compared with Professional Affiliation of the participant groups: Counseling Professionals and Psychology Professionals. This analysis showed significant difference in the self-perception of the use of all four of the domains between the two participants groups related to the domains of Knowledge, Awareness, Understanding and Interventions with f = 5.835, p = .018; f = 8.516, p = .004; f = 8.809, p = .000 and f = 25.188, p = .000 respectively. A Wilks? Lambda probability distribution analysis resulted in f = 8.958, p (sig.) = .000, observed power = .999, p < .05 which indicates significance in assessing the chance likelihood of the difference being due to chance. Table 5 shows the univariate analysis of variance (ANOVA) analysis of the participant perceptions of the nine competencies compared with Professional Affiliation of the participant groups: Counseling Professionals and Psychology Professionals. This analysis resulted in seven competencies indicating a significant difference in the self- perception of use between the two participant groups related to the competencies 1, 2, 3, 5, 6, 7, and 8 with f = 9.273, p = .003; f = 4.954, p = .028; f = 12.384, p = .001; f = 18.163, p = .000; f = 18.750, p = .000; f = 19.915, p = .000; and f = 41.652, p = .000 respectively. A Wilks? Lambda probability distribution analysis resulted in f = 6.952, p 66 (sig.) = .000, observed power = 1.000, p < .05 which indicates significance in assessing the likelihood of the difference being due to chance. Table 4 Competencies Domain by Professional Affiliation Domain Counseling Psychology Professionals Professionals n = 72 n = 22 Mean SD Mean SD f p (sig.) Knowledge 4.05 .766 3.61 .668 5.835 .018 * Awareness 4.25 .777 3.71 .790 8.516 .004 ** Understanding 4.23 .664 3.50 .799 18.809 .000 *** Interventions 3.88 .728 2.87 1.097 25.188 .000 *** Note: Wilks? Lambda = 8.958, p = .000, Observed power = .999, p < .05 * p < .05, ** p < .01, *** p < .001 Table 5 Competency by Professional Affiliation Competency Counseling Psychology (Thematic coding) Professionals Professionals n = 72 n = 22 Mean SD Mean SD f p (sig.) 1 4.04 .827 3.42 .847 9.273 .003 ** (Differentiation) 2 4.00 .782 3.58 .781 4.954 .028 * (Cultural Context) 3 4.26 .818 3.51 1.039 12.384 .001 ** (Self-Awareness) 4 4.16 .809 3.94 .648 1.334 .251 (Development) Table 5 continued 67 Competency Counseling Psychology (Thematic coding) Professionals Professionals n = 72 n = 22 Mean SD Mean SD f p (sig.) 5 4.51 .714 3.77 .693 18.163 .000 *** (Acceptance) 6 3.84 .831 2.88 1.144 18.750 .000 *** (Assessment) 7 4.08 .704 3.21 1.082 19.915 .000 *** (Respect) 8 3.97 .744 2.50 1.391 41.652 .000 *** (Therapeutic Use of Beliefs) 9 4.00 .754 3.73 .636 2.403 .125 (Limits of Understanding) Note: Wilks? Lambda = 6.952, p = .000, Observed power = 1.000, p < .05 * p < .05, ** p < .01, *** p < .001 An ANOVA to identify the difference between the groups of Professional Affiliation and the four spiritual competencies domains is shown in Table 6. A significant difference is shown in the self-perception of use of the domains of Awareness, Understanding and Intervention with counseling professionals showing more use of the domains than psychology professionals. An analysis of the self-perceived use of the competencies (Table 7) shows that competencies 1, 3, 5, 6, 7 and 8 are all followed more closely in self-report by counseling professionals than by psychology professionals. 68 Table 6 Univariate Comparison of Domains by Professional Affiliation Domain F Sig. Observed Group Power (a) Comparison Knowledge 5.835 .018 * .666 G1 > G2 Awareness 8.516 .004 ** .823 G1 > G2 Understanding 18.809 .000 *** .990 G1 > G2 Interventions 25.188 .000 *** .999 G1 > G2 * p < .05, ** p < .01, *** p < .001 G1 ? Counseling Professionals G2 ? Psychology Professionals Table 7 Univariate Comparison of Competencies by Group Competency F Sig. Observed Group (Thematic coding) Power (a) Comparison 1 9.273 .003 ** .854 G1 > G2 (Differentiation) 3 12.384 .001 ** .936 G1 > G2 (Self-Awareness) 5 18.163 .000 *** .988 G1 > G2 (Acceptance) 6 18.750 .000 *** .990 G1 > G2 (Assessment) 7 19.915 .000 *** .993 G1 > G2 (Respect) 8 41.652 .000 *** 1.000 G1 > G2 (Therapeutic Use of Beliefs) * p < .05, ** p < .01, *** p < .001 G1 ? Counseling Professionals G2 ? Psychology Professionals 69 Question 4: How do counseling and psychology professionals differ in their spiritual awareness, understanding, knowledge, and interventions skills based on their demographic characteristics? Age Table 8 shows the MANOVA results of the participant perceptions of the four domains of Knowledge, Awareness, Understanding and Interventions compared with the reported age of the survey participants. The analysis of the age ranges of the participants, 21-30 years, 31-40 years, 41-50 years, 51-60 years and 61+ years of age showed significant difference in the self-perception of use of one of the domains, Understanding (Table 8) and two of the competencies, 1 and 8 (Table 9) between several of the five age groups. The domains of Understanding showed significance with f = 2.691, p = .036 and a Wilks? Lambda probability distribution analysis resulted in f = 1.542, p(sig.) = .085, observed power = .757, p < .05. The use of the competencies 1 and 8 showed significance with f = 3.881, p = .006 and f = 2.983, p = .023 respectively and a Wilks? Lambda of 1.485, p = .042, Observed power = .984 indicates significance in assessing the likelihood of the difference being due to chance. Table 8 Domain by Age Analysis Domain 21-30 years 31-40 years 41-50 years 51-60 years 61+ years n = 10 n = 22 n = 31 n = 21 n = 10 Mean SD Mean SD Mean SD Mean SD Mean SD f p (sig.) Knowledge 3.70 .844 3.83 .695 3.83 .739 4.36 .577 3.91 1.039 2.251 .070 Awareness 3.76 1.001 4.08 .762 4.04 .754 4.45 .647 4.24 1.082 1.531 .200 Understanding 3.98 .699 4.02 .703 3.83 .802 4.50 .430 4.04 1.067 2.691 .036 * Interventions 3.60 .758 3.45 1.053 3.44 .923 4.10 .731 3.77 .984 2.021 .098 Note: Wilks? Lambda = 1.542, p = .085, Observed power = .757, p < .05 * p < .05 70 Table 9 Competency by Age Analysis Competency 21-30 years 31-40 years 41-50 years 51-60 years 61+ years (Thematic coding) n = 10 n = 22 n = 31 n = 21 n = 10 Mean SD Mean SD Mean SD Mean SD Mean SD f p (sig.) 1 (Differentiation) 3.50 .943 3.76 .738 3.69 .858 4.48 .586 3.96 1.114 3.881 .006 ** 2 (Cultural Context) 3.83 .698 3.84 .844 3.77 .778 4.29 .624 3.73 1.050 1.633 .173 3 (Self-Awareness) 3.86 1.036 4.02 1.015 3.96 .827 4.39 .777 4.18 1.191 .896 .470 4 (Development) 3.73 1.040 3.95 .645 4.12 .728 4.37 .706 4.23 .956 1.468 .219 5 (Acceptance) 4.33 .629 4.35 .646 4.10 .835 4.73 .389 4.23 1.248 2.276 .067 6 (Assessment) 3.53 .916 3.39 1.071 3.46 1.033 4.07 .751 3.70 1.092 1.669 .164 7 (Respect) 3.73 .815 3.80 .947 3.71 .918 4.27 .642 3.88 1.049 1.477 .216 8 (Therapeutic Use 3.78 .759 3.35 1.243 3.27 1.163 4.21 .888 3.90 .966 2.983 .023 * of Beliefs) 9 (Limits of 3.57 .804 3.95 .658 3.81 .727 4.25 .586 4.00 .972 1.900 .117 Understanding) Note: Wilks? Lambda = 1.485, p = .042, Observed power = .984, p < .05 * p < .05, ** p < .01 71 72 The results of a Bonferroni post hoc test to identify the difference between the age ranges of survey participants and the domain of Understanding is shown in Table 10. A significant difference is shown in the self-perception of use of the domains by those survey participants that stated they were between the ages of 51-60 years old and those that stated they were between 41-50 years old. This was continued in Table 11 as the survey participants within the age range of 51-60 years old showed significant differences with two of the four other age ranges analyzed with competencies 1 and 8 being more regularly demonstrated in the self-report of the survey participants. Table 10 Univariate Comparison of Domains by Age Domain F Sig. Observed Age Power (a) Comparison Understanding 2.691 .036 * .726 51-60 > 41-50 * p < .05, ** p < .01, *** p < .001 Table 11 Univariate Comparison of Competencies by Age Competency F Sig. Observed Age (Thematic coding) Power (a) Comparison 1 3.881 .006 ** .885 51-60 > 21-30 (Differentiation) 51-60 > 41-50 8 2.983 .023 * .776 51-60 > 41-40 (Therapeutic Use of Beliefs) * p < .05, ** p < .01 73 Gender Table 12 shows the data for the responses of the survey participants with respect to gender and the domains of Knowledge, Awareness, Understanding and Interventions. This analysis showed significant difference in the self-perception of use of three of the domains in relation to the gender of the survey participants with Knowledge, Understanding and Interventions, showing f = 4.244, p = .042; f = 10.114, p = .002; and f = 8.110, p = .005 respectively. A Wilks? Lambda probability distribution analysis resulted in f = 3.400, p (sig.) = .012, observed power = .834, p < .05 which indicates significance in assessing the chance likelihood of the difference occurring. Table 13 shows the MANOVA of the participant perceptions of the nine competencies when compared to the gender of the survey participants. This analysis resulted in seven competencies indicating a significant difference in the self-perception of use between the two participant groups related to the competencies 1, 2, 3, 5, 6, 7, and 8 with f = 4.315, p = .041; f = 5.925, p = .017; f = 4.062, p = .047; f = 10.273, p = .002; f = 6.376, p = .013; f = 7.699, p = .007; and f = 10.343, p = .002 respectively. A Wilks? Lambda probability distribution analysis resulted in f = 2.488, p (sig.) = .014, observed power = .908, p < .05 which indicates significance in assessing the likelihood of the difference being due to chance. 74 Table 12 Domain by Gender Analysis Domain Female Male n = 56 n = 38 Mean SD Mean SD f p (sig.) Knowledge 4.08 .642 3.75 .889 4.244 .042 * Awareness 4.23 .665 3.98 .997 2.277 .135 Understanding 4.26 .510 3.77 .961 10.114 .002 ** Interventions 3.86 .664 3.32 1.155 8.110 .005 ** Note: Wilks? Lambda = 3.400, p = .012, Observed power = .834, p < .05 * p < .05, ** p < .01 Table 13 Competency by Gender Analysis Competency Female Male (Thematic Coding) n = 56 n = 38 Mean SD Mean SD f p (sig.) 1 (Differentiation) 4.04 .713 3.67 1.025 4.315 .041 * 2 (Cultural Context) 4.06 .640 3.68 .951 5.383 .023 * 3 (Self-Awareness) 4.24 .696 3.86 1.159 4.062 .047 * 4 (Development) 4.14 .752 4.05 .818 .304 .583 5 (Acceptance) 4.54 .503 4.04 .987 10.084 .002 ** 6 (Assessment) 3.85 .779 3.26 1.174 8.454 .005 ** 7 (Respect) 4.09 .602 3.56 1.120 8.870 .004 ** 8 (Therapeutic Use 3.94 .712 3.16 1.418 12.370 .001 ** of Beliefs) 9 (Limits of 3.96 .660 3.90 .839 .157 .692 75 Understanding) Note: Wilks? Lambda = 2.488, p = .014, Observed power = .908, p < .05 * p < .05, ** p < .01 The results of a Bonferroni post hoc test to identify the difference between the gender of survey participants and the three domains of Knowledge, Understanding and Interventions are shown in Table 14. A significant difference was found in the self- perception of use of the domains between female participants and male participants. This was continued in Table 15 as the female survey participants showed significant differences from the males surveyed with competencies 1, 2, 3, 5, 6, 7 and 8 being more regularly demonstrated in the self-report by female survey participants. Table 14 Univariate Comparison of Spiritual Competencies Domains by Gender Domain F Sig. Observed Gender Power (a) Comparison Knowledge 4.244 .042 * .531 Female > Male Understanding 10.114 .002 ** .882 Female > Male Interventions 8.110 .005 ** .805 Female > Male * p < .05, ** p < .01 Table 15 Univariate Comparison of Spiritual Competencies by Gender Competency F Sig. Observed Gender (Thematic coding) Power (a) Comparison 1 4.315 .041 * .538 Female > Male (Differentiation) Table 15 continued 76 Competency F Sig. Observed Gender (Thematic coding) Power (a) Comparison 2 5.383 .023 * .632 Female > Male (Cultural Context) 3 4.062 .047 * .514 Female > Male (Self-Awareness) 5 10.084 .002 ** .881 Female > Male (Acceptance) 6 8.454 .005 ** .820 Female > Male (Assessment) 7 8.870 .004 ** .838 Female > Male (Respect) 8 12.370 .001 ** .936 Female > Male (Therapeutic use of Beliefs) * p < .05, ** p < .01 Years of Professional Experience Table 16 shows the MANOVA of the participant perceptions of the four domains of Knowledge, Awareness, Understanding and Interventions compared with the reported years of professional experience of the survey participants and Table 17 reports the survey participants self-reported perceptions of the nine competencies. This analysis showed no significant differences between the four participant groups self-perception related to the use of the four domains or nine competencies. 77 Table 16 Domain by Years of Professional Experience Analysis Domain 0-4 years 5-9 years 10-14 years 15+ years n = 17 n = 35 n = 25 n = 17 Mean SD Mean SD Mean SD Mean SD f p (sig.) Knowledge 3.82 .885 3.86 .682 3.98 .874 4.18 .620 .838 .476 Awareness 4.01 .877 4.07 .836 4.13 .881 4.37 .563 .676 .569 Understanding 3.96 .931 3.98 .655 4.01 .902 4.42 .448 1.546 .208 Interventions 3.57 1.023 3.49 .860 3.56 1.062 4.13 .610 2.048 .113 Note: Wilks? Lambda = .744, p = .707, Observed power = .376, p < .05 Table 17 Competency by Years of Professional Experience Analysis Competency 0-4 years 5-9 years 10-14 years 15+ years (Thematic coding) n = 17 n = 35 n = 25 n = 17 Mean SD Mean SD Mean SD Mean SD f p (sig.) 1 3.75 .936 3.76 .775 3.91 1.010 4.29 .675 1.704 .172 (Differentiation) 2 3.72 .972 3.90 .736 3.93 .865 4.06 .653 .513 .674 (Cultural Context) 3 3.94 1.116 4.06 .940 4.07 .962 4.29 .633 .426 .735 (Self-Awareness) 4 4.10 .856 3.95 .750 4.13 .850 4.39 .592 1.248 .297 (Development) 5 4.24 .991 4.31 .631 4.27 .948 4.59 .449 .772 .513 (Acceptance) Table 17 continued 78 Competency 0-4 years 5-9 years 10-14 years 15+ years (Thematic coding) n = 17 n = 35 n = 25 n = 17 Mean SD Mean SD Mean SD Mean SD f p (sig.) 6 3.57 1.145 3.46 .904 3.54 1.117 4.07 .738 1.583 .199 (Assessment) 7 3.75 1.058 3.77 .830 3.83 .984 4.28 .544 1.494 .221 (Respect) 8 3.57 1.110 3.45 1.048 3.51 1.393 4.19 .590 1.895 .136 (Therapeutic Use of Beliefs) 9 3.84 .901 3.85 .686 3.89 .718 4.29 .614 1.689 .175 (Limits of Understanding) Note: Wilks? Lambda = .701, p = .864, Observed power = .611, p < .05 Racial/Ethnic Affiliations Table 18 shows the MANOVA of the participant perceptions of the four domains of Knowledge, Awareness, Understanding and Interventions compared with their self- reported Racial/Ethnic Affiliations of; African-American, Hispanic, Multiracial, and White (Caucasian). No significant differences were found in the self-perception of use of the four domains of Knowledge, Awareness, Understanding and Interventions. In an analysis of the self-perception of use of the competencies among the Racial/Ethnic Affiliations of the survey participants, two of the competencies 5 and 9 (Table 19) showed significance with f = 3.422, p = .021; and f = 4.616, p = .005 respectively. A Wilks? Lambda probability distribution analysis resulted in f = 1.732, p(sig.) = .061, observed power = .803, p < .05. The use of the competencies 5 and 8 showed significance with f = 3.422, p = .021 and f = 4.616, p = .005 respectively and a Wilks? Lambda of 79 1.948, p = .005, Observed power = .994 indicates significance in assessing the chance likelihood of the difference. Table 18 Domain by Racial/Ethnic Affiliation Analysis Domain African Hispanic Multiracial Caucasian American n = 11 n = 3 n = 12 n = 68 Mean SD Mean SD Mean SD Mean SD f p (sig.) Knowledge 3.78 .855 2.92 1.348 3.89 .444 4.03 .746 2.345 .078 Awareness 3.92 .984 3.52 1.592 4.21 .620 4.18 .776 .913 .438 Understanding 3.92 .753 3.21 .971 4.05 .645 4.13 .763 1.595 .196 Interventions 3.61 .822 3.09 .241 3.38 .784 3.72 .980 .824 .484 Note: Wilks? Lambda = 1.732, p = .061, Observed power = .803, p < .05 * p < .05, ** p < .01, *** p < .001 Table 19 Competency by Racial/Ethnic Affiliation Analysis Competency African Hispanic Multiracial Caucasian (Thematic American coding) n = 11 n = 3 n = 12 n = 68 Mean SD Mean SD Mean SD Mean SD f p (sig.) 1 3.66 .976 2.75 1.299 3.75 .533 4.01 .849 2.629 .055 (Differentiation) 2 3.91 .769 3.00 1.391 3.98 .482 3.93 .814 1.358 .261 (Cultural Context) 3 3.95 .980 3.67 1.702 4.27 .617 4.09 .938 .431 .731 (Self-Awareness) Table 19 continued 80 Competency African Hispanic Multiracial Caucasian (Thematic American coding) n = 11 n = 3 n = 12 n = 68 Mean SD Mean SD Mean SD Mean SD f p (sig.) 4 3.85 .935 3.22 1.388 3.94 .617 4.22 .723 2.433 .070 (Development) 5 4.00 .760 3.22 1.347 4.50 .577 4.41 .740 3.422 .021 * (Acceptance) 6 3.48 .918 3.17 .629 3.33 .764 3.701.052 .762 .519 (Assessment) 7 3.83 .693 3.58 1.127 3.83 .763 3.90 .935 .150 .930 (Respect) 8 3.68 .902 3.25 .661 3.33 .931 3.681.196 .442 .724 (Therapeutic Use of Beliefs) 9 3.80 .857 2.67 .382 3.71 .601 4.06 .689 4.616 .005 ** (Limits of Understanding) Note: Wilks? Lambda = 1.948, p = .005, Observed power = .994, p < .05 * p < .05, ** p < .01 A Bonferroni post hoc test to identify the difference between the reported Racial/Ethnic Affiliation of the survey participants and the two competencies 5 and 9 is shown in Table 20. A significant difference was shown in the self-perception of use of the competencies by Caucasian participants and Hispanic participants. 81 Table 20 Univariate Comparison of Competencies by Racial/Ethnic Affiliation Competency F Sig. Observed Cultural Affiliation (Thematic coding) Power (a) Comparison 5 3.422 .021 * .753 Caucasian > Hispanic (Acceptance) 9 4.616 .005 ** .878 Caucasian > Hispanic (Limits of Understanding) * p < .05, ** p < .01 Academic Achievement Table 21 shows the MANOVA of the participant perceptions of the four domains of Knowledge, Awareness, Understanding and Interventions compared with the level of academic achievement of the survey participants. Table 22 reports the survey participants? self-reported perceptions of the nine competencies. This analysis showed no significant differences between the three participant groups? self-perception related to the use of the four domains or nine competencies. Table 21 Domain by Level of Academic Achievement Analysis Domain Doctorate Educational Master?s Specialist n = 22 n = 5 n = 67 Mean SD Mean SD Mean SD f p (sig.) Knowledge 4.02 .889 4.01 .621 3.91 .738 .201 .818 Awareness 4.00 1.062 4.63 .412 4.13 .730 1.217 .301 Understanding 3.95 1.049 4.03 .615 4.10 .666 .350 .706 Interventions 3.49 1.293 3.62 .822 3.69 .794 .407 .667 Note: Wilks? Lambda = 2.430, p = .016, Observed power = .891, p < .05 82 Master?s includes M.A./M.S./M.Ed./M.Div. Table 22 Competency by Level of Academic Achievement Analysis Competency Doctorate Educational Master?s (Thematic coding) Specialist n = 22 n = 5 n = 67 Mean SD Mean SD Mean SD f p (sig.) 1 3.93 1.041 3.93 .824 3.88 .820 .038 .963 (Differentiation) 2 3.93 .983 3.90 .576 3.90 .755 .017 .983 (Cultural Context) 3 3.85 1.253 4.65 .418 4.12 .809 1.698 .189 (Self-Awareness) 4 4.20 .808 4.33 .527 4.06 .785 .479 .621 (Development) 5 4.21 1.067 4.40 .683 4.37 .665 .373 .690 (Acceptance) 6 3.48 1.329 3.50 .848 3.67 .883 .321 .726 (Assessment) 7 3.73 1.200 3.75 .586 3.93 .782 .501 .608 (Respect) 8 3.27 1.580 3.80 1.137 3.72 .915 1.430 .245 (Therapeutic Use of Beliefs) 9 4.06 .783 4.05 .737 3.89 .723 .481 .620 (Limits of Understanding) Note: Wilks? Lambda = 1.459, p = .111, Observed power = .884, p < .05 Master?s includes M.A./M.S./M.Ed./M.Div. 83 V. DISCUSSION Religion and spirituality have an important place in American society and culture and can have a significant influence on the development of a client's attitudes and behavior. Spirituality is often an important part of the issues a client brings to counseling, including personal, social, relationship and development issues (Bishop, Avila-Juarbe, & Thumme, 2003) and may need to be recognized and validated in the client's experience. In crisis situations people often turn to religious and spiritual support (Worthington, 1989) and, when faced with significant stress, clients may prefer a counselor who is sensitive to spiritual issues (Burke et al., 1999; McLennan et al., 2001). To ignore the spiritual aspects of a person?s life and worldview may be to neglect a fundamental part of the client's identity and life (Burke et al., 1999; McLennan et al., 2001; Miller, 1999; Wiggins-Frame, 2003; Young, Wiggins-Frame, & Cashwell, 2007). With nearly one-quarter of Americans not affiliated with Christian religious groups (Kosmin et al., 2001) and awareness of diversity within the American population continually increasing, counselors will be interacting with more diverse populations than ever before as religious diversity increases due to an ?increased level of education, world- consciousness, and individualism and immigration? (Hoge, 1996, p. 38). This interaction would likely include those non-mainstream spirituality populations that hold Unitarian Universalist, Pagan, Spiritualist, and Native American spiritual beliefs as well as immigrants to the United States who bring spiritual beliefs unique to their cultural and 84 ethnic backgrounds. This could also include those people who hold agnostic, atheistic or alternative spiritual beliefs that have no correspondence with mainstream American religious practices. This range of religious and spiritual practices brought to counseling sessions by clients can be as varied as the people using them, and may not necessarily correspond with the background and training of the practitioners (Clark, 2002; D'Andrea & Sprenger, 2007; Hodge, 2005; Khalid, 2006; Levitt & Balkin, 2003; McLennan et al., 2001). Therefore, it is necessary for counselors to understand how their own religious and spiritual culture may differ from that of the general populace and the clients whom they serve (Walker, Gorsuch, & Tan, 2004). In an effort to further the integration of religion and spirituality awareness into counseling practice the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) developed what has become accepted as the necessary spiritual competencies for counselors to ethically integrate religion and spirituality into counseling practice (Miller, 1999). These competencies focused on the (a) knowledge of spiritual phenomena, (b) awareness of one's own spiritual perspective, (c) understanding clients' spiritual perspectives, and (d) understanding spiritually related interventions and strategies (Hage et al., 2006). The primary objective of this study was to obtain information regarding the spiritual practices and competencies current mental health practitioners, professional counselors and counseling psychologists, use in their clinical practice; particularly the extent of inclusion of spiritual knowledge, awareness, skills and interventions as they relate to the ASERVIC spiritual competencies. This study also sought to investigate how 85 the use of these competencies varied between professional counselors and counseling psychologists as well as across demographic differences in the survey participants. Discussion of the Findings This study was intended to develop information about the self-perceptions and practices of counseling professionals and their inclusion of knowledge of religious and spiritual phenomena and the influence religion/spirituality may have on individual and cultural identity; the counselor?s awareness of their own religious and spiritual perspectives, biases and directions for growth; the counselor?s understanding of a client?s needs and awareness in regards to religious/spiritual issues; and the counselor?s ability to utilize religious and spiritually appropriate interventions in the counseling process. The survey data was analyzed from the perspective of the components of competent spiritual practice as they presented through the accepted spiritual competencies as defined by ASERVIC (Appendix D) and the four domains of Knowledge, Awareness, Understanding and Interventions that support the inclusion of spiritual competency in counselor practice. Research Question 1: What spiritual knowledge, awareness, understanding, and interventions do counseling professionals exercise in their counseling practice? Research question one pertained to the components of spiritual competencies that counseling professionals used and may have found essential for delivery of effective counseling practices with their clients. In this study, counseling professionals showed their knowledge, awareness, and understanding of spiritual and religious issues to be predominately used with interventions being used less frequently. In the application of 86 the competencies, counseling professionals were consistent in their use with all of the nine competencies being frequently employed in client interactions and personal development. The tendency of this study?s participants to use spiritual and religious knowledge, awareness and understanding supports the positive attitude counselor educators have toward religion and spirituality (Kelly, 1994; Pate & High, 1995) and the importance of the ASERVIC spiritual competencies (Young et al., 2007). However, it is difficult to distinguish the natural tendency of counselors, as regards the inclusion of personal religious and spiritual aspects in counseling practice, from the effects of training in religious and spiritual issues in counselor education programs (Bishop et al., 2003; Fukuyama & Sevig, 1997) when attempting to determine which has a greater influence on counselor practice. With a high percentage of the American population believing in God or higher powers and the importance of religious and/or spiritual focus in one?s life (Kosmin et al., 2001), it might be assumed that counselors are acting in accordance with their own religious or spiritual compass and not from a place of professional training. Another potential influence that may account for the frequent use of the spiritual domains and competencies among counselors in this study is the influence of multiculturalism on the profession of counseling. As religious beliefs of clients must be considered equally with cultural values if diversity among clients is to be respected (Pate & Bondi, 1992) and spirituality is accepted as an integral part of many people's racial and cultural identity (Bergin, Payne, & Richards, 1996; Eck & Moon, 2002; Fukuyama & Sevig, 1999; Hage et al., 2006), then the acceptance of the fundamental importance of 87 multicultural diversity (Arredondo et al., 1996; Bishop et al., 2003; Powers, 2005; Richards & Bergin, 2000a; Stanard et al., 2000; Sue et al., 1992) may account for the acceptance of religious diversity in this study. This is potentially supported by the higher frequency of use of the competency of Acceptance by this study?s participants and the lower occurrence of use of the competency of Assessment. Overall, the results of this study as regards the practices of counseling professionals are supportive of the counseling professionals? ability to establish rapport with clients who desire a spiritually aware counselor. These clients, in times of crisis, frequently turn to mental health professionals and respond well to counselors who exhibit an awareness of the religious and spiritual aspects in a person?s life. This is true even when the issues that brought the client to counseling do not directly involve religious or spiritual elements (Burke et al., 1999; McLennan et al., 2001). This study?s results showing counseling professionals tendency to use and exhibit spiritually competent knowledge, awareness, understanding and acceptance of clients? religious and spiritual perspectives may indicate an ability of counselors to establish rapport with clients of some marginalized populations and thus develop a more productive counseling relationship. Research Question 2: What spiritual knowledge, awareness, understanding, and interventions do psychology professionals exercise in their counseling practice? Research question two reviewed the components of spiritual competencies that psychology professionals used in their clinical approaches with clients. Overall, these professionals generally integrated their knowledge, awareness and understanding of a 88 client?s religious and spiritual issues into the counseling process. Their awareness of religious and spiritual issues was ranked the highest in utilization among the domains and their use of interventions specific to a client?s religious and spiritual orientations ranked the lowest. Their use of the spiritual competencies was led by their understanding of the role religious and spiritual influences can play in a person?s development while their therapeutic use of clients? religious and spiritual beliefs was the least used spiritual competency. Although psychology has been influenced by the works of Jung, Adler and Maslow (Davis, 1914; Kelly, 1992; Parsons, 1967; Powers, 2005) each of whom demonstrated a valuing of a morally aware social context, it has primarily marginalized religious and spiritual issues in the practice of psychology (Harper & Gill, 2005; Kelly 1992) with the separation of religious and spiritual values from the practice of counseling (Hagedorn, 2005). This practice continues with few mental health practitioners receiving formal training in working with spiritual and religious issues in counseling (Brawer, Handal, Fabricatore, Roberts, & Wajda-Johnston, 2002; Burke et al., 1999; Genia, 1994; Schulte, Skinner, & Claiborn, 2002; Shafranske & Malony, 1990; Shafranske & Malony, 1996; Wiggins-Frame, 2003; Young et al., 2007). This leaves secular psychologists and therapists, being more scientifically-based than their religiously-based counterparts and may lead them to avoid working with the structures of formalized religious beliefs and practices (Kelly, 1992) so as not to compromise the scientific basis of their disciplines. Even the value by the general population of religious and spiritual issues seems to be mitigated by the influence of professional training as studies have shown that while 89 therapists may personally value religious and spiritual perspectives, they are less inclined to value religion than the general population (Bergin & Jensen, 1990; Eck & Moon, 2002; Shafranske & Malony, 1990; Shafranske & Malony, 1996). This reluctance to work with, and not just be aware of, the spiritual issues of their clients may be supported in the results of this study as it was shown that those with psychology orientations were inclined to be aware of religious and spiritual issues and understand the role religious and spiritual influences can play in a person?s development but were apt to avoid the use or inclusion of that awareness and understanding in their clinical practice. This dual edge of awareness and practice may account for the present study?s results showing that interventions and therapeutic use of client?s beliefs were the least utilized spiritual competency practices employed by psychology professionals who have not adequately reached the religious client while supporting the exemplary understanding and support by psychologists of cultural diversity with respect to race, gender, and ethnicity (Bergin, 1991). Research Question 3: How do counseling and psychology professionals differ in their spiritual knowledge, awareness, understanding, and interventions in clinical practice? Research question three pertains to the domains and areas of spiritual competency which mental health professionals use, and consider significant to differing degrees in their clinical practices. Analysis of the survey responses showed that counseling professionals ranked each of the four domains and each of the nine competencies higher than did the psychology professionals. In all four of the four domains, Knowledge, Awareness, Understanding and Interventions, the difference in responses between the two 90 professional groups was found to be significant. Notably, the highest ranked domain utilized by psychology professionals, Awareness, scored lower than did the lowest ranked domain utilized by counseling professionals, Interventions (Table 4). The use of the individual competencies by the two professional groups was similar to their use of the domains with the psychology professionals showing less use of the competencies as a whole with Assessment and Therapeutic Use of Beliefs being utilized least. In the utilization of the competencies seven of the nine competencies, Differentiation, Cultural Context, Self-Awareness, Acceptance, Assessment, Respect, and Therapeutic Use of Beliefs among the two groups were found to be significantly utilized less often by psychology professionals than by counseling professionals. While many professional associations have formally acknowledged religion in their ethical guidelines as one aspect of cultural diversity that counselors need to consider (e.g., American Counseling Association, 2005; American Psychological Association, 2002; Canadian Psychological Association, 2000), the profession of counseling has accepted the principles of multiculturalism as fundamental to the practice of counseling (Bishop et al., 2003; Hage et al., 2006; Pate & Bondi, 1992; Powers, 2005; Richards & Bergin, 2000a; Stanard et al., 2000; Sue et al., 1992). This respect for and inclusion of diversity by counseling professionals may account for the consistently greater use of spiritual and religious awareness, knowledge and understanding over that of psychology professionals. The frequency of the use of spiritual competencies may also be the influence of Council for Accreditation of Counseling and Related Educational Programs (CACREP) 91 accreditation standards (2001). In its 2001 accreditation standards CACREP included an awareness of spirituality in its core curricular requirements (Section 2, Program Objectives and Curriculum, K2 & K7) as well as in the foundational requirements for each area CACREP accredited. These standards promote the significance of training in spiritual and religious aspects of counseling (Hage et al., 2006) as shown by studies involving master's-level counselor education that suggest CACREP-accredited programs are more adequately equipped to provide spiritual and religious diversity training (Pate & High, 1995; Young et al., 2002) and to include a significant consideration of religious beliefs and practices in their foundational studies (Kelly, 1997). This incorporation of religious and spiritual awareness into program and course development and counselor training may provide a distinct change from past mental health training where the great majority rarely discussed religious or spiritual issues in training (Walker et al., 2004) and a move away from the bias against addressing religion in the therapy process (Eck & Moon, 2002). In this study can be seen a significant departure from this bias against including religious and spiritually related content in interactions with clients with counselors frequently addressing the place and significance of religion and spirituality in a client?s issues and world. Research Question 4: How do counseling and psychology professionals differ in their spiritual awareness, understanding, knowledge, and interventions skills based on their demographic characteristics? The differences of the survey responses when separated by age group showed significant differences in the use of the overall spiritual competencies. While all age 92 groups reported that they generally acted in accordance with the domains and competencies the age range of 51 to 60 years consistently rated themselves as doing so very frequently which put their professional practices of spiritual Knowledge, Understanding and Interventions as well as the competencies of Differentiation, Acceptance and Therapeutic use of Beliefs significantly above those of all other age ranges. Lacking significant results the 61+ years age range reported more general spiritual and religious awareness than their younger peers under the age of 50, with the age ranges of 21 to 30 years, 31 to 40 years and 41 to 50 years showing similar results to each other. While generally supporting the findings of Kosmin et al. (2001) that religious and spiritual outlooks increase with age, the results of this study show that the age range of 51 to 60 years old are the most apt to be spiritually and religiously aware, understanding and knowledgeable. This does not support Kosmin et al.?s findings that the age range of 65+ is more spiritually and religiously aware and involved than all younger age ranges. This may be in the fact that the Kosmin study was across the general U.S. population while this study focused on mental health professionals who are required to pursue continuing education. When viewed from the perspective of gender, females who participated in this study consistently showed significantly more use of the domains of Knowledge, Understanding and Interventions as well as the individual competencies of Cultural Context, Acceptance, Assessment, Respect, and Therapeutic Use of Beliefs than the males. Once again, while generally supporting the findings of Kosmin et al., (2001), this 93 study showed that women far more often employed religious and spiritual knowledge and understanding than men, potentially beyond the self-reported religious outlook differences found by Kosmin et al. Lower use of every domain and competency by males may be explained by the lower self-report of religious outlook in males but is not supported in the research literature. Kosmin et al. assumed that only a religiously or spiritually minded person would employ religious and/or spiritual aspects in their counseling practice. However such relationships between the use of the spiritual domains and/or competencies and the religious outlook of the counseling or psychology practitioner should be further examined in future studies. Years of professional experience of the survey participants showed no significant results across any experience range. However, those survey participants which identified having 15+ years of professional experience showed consistent frequent use of the domains and competencies as well as higher overall scores than those with less professional experience. Just as with age, spiritual awareness, understanding and knowledge may increase over time through accrued personal experience and be accelerated with continued exposure to continuing education, however, no study has yet investigated the change of religious and spiritual perspectives in clinical practitioners over the course of their professional careers. Racial/ethnic affiliation showed no significance in regards to the domains but did show significance in the competencies of Differentiation, Acceptance and Limits of Understanding with the Caucasian participants reporting more use of the competencies than the Hispanic participants. Although no studies have investigated the influence of 94 racial and ethnic affiliation on religious and spiritual perspectives in mental health practitioners, no other demographic factor in this study has more influence than the inclusion and integration of diversity on the counseling profession. Perhaps the results found in this study reflect the growing awareness of the processes of racial identity development and the continuing influence of multicultural awareness in both the counseling and psychology professions (Bergin, 1991; Bergin, Payne, & Richards, 1996; Eck & Moon, 2002; Fukuyama & Sevig, 1999; Hage et al., 2006). The level of academic achievement appeared to have no significant impact on the use and perception of the spiritual competencies among the survey participants. Even among general comparison of the group responses no group showed itself to more or less frequently make use of the domains and individual competencies. Limitations The primary limitation of this study is in the difficulty in defining religion and spirituality in such a way that is unambiguous to the study participants. Although the operational definitions for this study may have attempted to define these terms, personal, ethnic and cultural perceptions of religion and spirituality could have informed the participant?s answers. The survey questions for this study were developed by the researcher by examining existing literature that describes the knowledge, awareness, understanding and interventions that clinical practitioners use in their work. This method resulted in a non- standardized assessment whose validity and reliability are questionable and may not accurately depict or describe the actual behaviors and processes of the mental health 95 professionals that participated in this study. Therefore, while significant results were found in the responses of the survey participants between many of the independent and dependent variables, no causation can be assumed. The self-report format of the survey creates significant limitations as it does not allow the survey participants answers to be checked for personal or social desirability bias as regards their actual behaviors and processes or to be checked against other more validated assessments. The potential for participants to answer the study questions according to what would be favorably viewed by others may have biased the participants of this study towards responses that do not actually exist in the clinicians? practices. The non-random nature of the data collection used a purposeful sample approach to enlist the participation of mental health professionals. This may impact the representativeness of the sample and limit the generalizability of this study to a broader population of clinicians. While the email invitations to participate in this study were sent directly and exclusively to members of LPCAGA, the snowball sampling method used may have enlisted survey participants outside of that population. Future studies should engage a broader sample of mental health professionals to ensure adequate representation of both various counseling and mental health approaches (e.g. Licensed Clinical Social Workers and Marriage and Family Therapists) and the profession of counseling as a whole. Particularly helpful would be the inclusion of more psychologists (psychology professionals who have achieved a Ph.D.) in the study to balance the number of counseling professionals with Ph.D.?s with a comparable educational background. It should include sufficient sample sizes to adequately support any significant findings and 96 should more distinctly distinguish between the professional groups to better allow any significant finding to be adequately explored as regards professional training and orientation. To counter many of these limitations, future studies of this nature should incorporate a qualitative aspect that could delve deeper into clinicians? approaches to working with spiritual and religious issues. This could then be used to corroborate the self-report responses of the survey participant to counter the potential of social desirability bias as well as provide examples of best practices of successful integration of spiritual competency into clinical practice. Implications The results of this study show that the utilization of spiritual competency in clinical practice is complex and influenced by multiple factors. The movement to incorporate spiritual awareness and competency into mental health training has been growing as shown in the inclusion of spirituality in the ethical standards of many professional associations (e.g., American Counseling Association, 2005; American Psychological Association, 2002; Canadian Psychological Association, 2000). This is supported in this study by the utilization of the spiritual domains and competencies by counseling and psychology professionals. Counselor Education In the current study counseling professionals appeared to more frequently use the spiritual competencies than psychology professionals. However, the current study did not show that current graduates, who were more likely to be better exposed to curriculums 97 that incorporate spirituality as factors of counseling, have used the spiritual competencies in their practice more frequently when compared to their professional counterparts. This may show that counselors recognize the importance of inclusion of spiritual competencies into their practices but highlights the need for counselor education programs to move beyond the current state of inclusion of awareness of religious and spiritual factors into counselor practice and include best practice strategies to incorporate this awareness into counselor training. To do this may require an examination of the teaching methods of spirituality in graduate education curriculums. Considering that experienced (15 years and more) and older (ages 51-60) mental health professionals in the current study are more likely to use the spiritual competencies, a reflective teaching approach may have better results in enhancing pre-service mental health providers ability to incorporate spiritual competencies in future practice. Also, a move toward the teaching of spiritual competencies by those populations that have shown greater awareness and use of them may advance the practical application of the spiritual competencies in clinical practice. Counseling Practice A significant implication of this study for counseling practitioners is that clinicians may already incorporate the fundamentals of spiritually competent practices into their work with clients. The identification would allow clinicians to reflect on the extent of integration of their existing spiritual awareness and to become conscientious in choosing which competencies need to be addressed to promote the counseling relationship and the resolution of client issues. 98 Mental health practitioners should also pursue continuing education opportunities in spiritual training to enhance their ability to work with clients with diverse religious backgrounds. This could take many forms of interaction with spiritual diversity including formal training, professional familiarity with religious and spiritual leaders from diverse religious backgrounds and interaction with members of non-mainstream religious and spiritual groups and organizations. Personal and professional knowledge in this area could greatly enhance a clinician?s ability to empathize with a client?s needs and would lead to greater understanding of a client?s worldview and the forces that motivate them. Research This study showed that many factors influence the integration of religious and spiritual awareness, knowledge, understanding and interventions into mental health practices. This study also highlights the need for research studies to provide further clarity in the competencies, to identify the contributing factors to clinician use of these competencies, and to identify clinical practices that promote best practices in the use of these competencies. Further development and clarification of the spiritual competencies is necessary. At this time the spiritual competencies are broad with each competency containing several areas of professional practice. Future research in this area could take the form of more comprehensive studies that further define what each competency is and how it could be exhibited in counselor practice. Investigations in this area could then focus on the presentation of those competencies from the perspective of both the counselor and the client. This may then allow researchers to focus on clinical behaviors and practices that 99 exemplify each competency and these practices could then be evaluated for clinical efficacy and application to the client?s issues. With this verification the efficacy of specific counseling techniques to integrate spiritual awareness and understanding specific interventions could be better determined that promote the counseling relationship. It would be relevant to determine to a greater degree of accuracy the correspondence of application of these spiritual competencies among clinical practitioners with their professional orientations, personal view of the value of religion and personal life experiences, and training and continuing education in this area that may have inclined or prepared them to work with religious and/or spiritual issues in clinical practice. Does age and professional experience account for the high level of use of the spiritual competencies as it appeared to be in this study? Or do other factors, such as professional orientation, have significant supportive or negative effects on the perception and utilization of spiritual competency? Further research would need to focus on these questions as well as the overall importance of demographic factors such as gender, age and racial/ethnic affiliation on counselor utilization of religious and spiritual awareness, knowledge and understanding. Summary This study shows that many factors can influence the delivery of spiritually competent mental health services. Gender, age, years of professional experience, racial/ethnic background, and professional affiliation are just a few of the variables that were identified in this study as influencing clinical practice. 100 The movement to include spiritual competency in mental health and counselor training programs and to encourage the development of spiritual competency in clinical practice has been advanced by the formulation of the ASERVIC spiritual competencies. These competencies have been developed as guidelines as to what knowledge, awareness, understanding and interventions support and promote spiritually competent practice. They also may provide a standard by which we can identify the changes necessary to improve counseling services and counselor training. 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Journal of Counseling & Development, 78(2), 162-171. Zinnbauer, B. J., Pargament, K. I., Cole, B., Rye, M. S., Butfer, E. M., Belavich, T. G., et al. (1997). Religion and spirituality: Unfuzzying the fuzzy. Journal for the Scientific Study of Religion, 36(4), 549-564. 117 APPENDICES 118 Appendix A Spiritual Competency Survey Recruitment Letter Dear Clinician, In this age of diversity, it is critical that mental health professionals pursue awareness, understanding, knowledge, and interventions to more effectively serve clients from diverse religious and spiritual backgrounds. Pursuant to this goal I am requesting your assistance in studying the competencies and characteristics which mental health clinicians find essential in serving clients with diverse backgrounds. If you choose to participate, you will be redirected to a website where you will be asked to complete a survey that will take about 15 minutes of your time. The first page of the survey is a comprehensive ?Information Sheet? which will explain more specifically the nature of this research study. I am sure that you agree that expanding the knowledge within our professional is essential to effectively serving our mental health clients and will join me in this endeavor! Any specific inquiries related to your participation in this study can be directed to me or my advisor?s attention as noted in the attached ?Information Sheet?. Thank you for your assistance. Sincerely, Keith Cates, Ed.S., LPC, Doctoral Candidate Department of Special Education, Rehabilitation, & Counseling/School Psychology College of Education Auburn University 119 Appendix B Spiritual Competency Survey Instructions and Survey Consent INFORMATION SHEET for a research study entitled ?Counselor Spiritual Competencies: An Examination of Counselor Practices? You are invited to participate in a research project designed to assess the spiritual components which clinicians exercise in providing mental health services. This study focuses on the impact of clinicians? importance and use of religious and spiritual awareness, knowledge, understanding and skills in their mental health practice. Keith Cates is conducting the study, under the supervision of Dr, Suhyun Suh, Committee Chair and Associate Professor in Auburn University?s Department of Special Education, Rehabilitation, Counseling/School Psychology. You were selected as a possible participant because you were identified as participating in counseling of individuals and groups and families in the state of Georgia; you were identified through either professional organizations or by other mental health professionals. If you choose to participate, you will be asked to complete the attached survey that will take about 15 minutes of your time. You may stop your participation in the survey at any time. As the data will be collected anonymously, it will not be possible to remove your individual date after you have submitted the survey. No possible risks or discomforts are anticipated with participation in this study, however, in case you experience any emotional discomfort during or after participation in the study it is recommended that you seek the assistance of a licensed professional counselor in your community. Please understand that you are responsible for any costs associated with medical or mental health treatment. Information collected in this study will be used in a doctoral dissertation, may be published in a professional journal, and/or presented at a professional meeting. All information will be collected anonymously so there will be no identifying information of any form included in the final results. If you have any questions, I invite you to contact me, Keith Cates, at (334) 844-5972 or cateska@auburn.edu, or my Faculty Advisor, Dr. Suhyun Suh, at (334) 844-2837 or suhsuhy@auburn.edu. For more information regarding your rights as a research participant, you may contact the Auburn University Office of Human Subjects Research or the Institutional Review Board by phone (334) 844-5966 or e-mail at hsubjec@auburn.edu or IRBChair@auburn.edu. 120 By clicking the ?I Agree? button at the bottom of this page you are agreeing to participate in this research study with a sufficient understanding of the benefits and risks involved. It is recommended that you print out this page to keep for informational purposes. Thank you. The Auburn University Institutional Review Board has approved this document for use from December 17, 2008 to December 16, 2009. Protocol #08-293 EX 0812. 121 Appendix C Spiritual Competency Survey Please respond to the following statements by indicating your level of agreement based on the following scale: 1 - strongly disagree / not at all 2 - disagree / not often 3 - neutral 4 - agree /often 5 - strongly agree / very often 1. I can explain the relationship between religion and spirituality, including similarities and differences. 2. I understand the potential similarities and differences between religion and spirituality. 3. I understand how spirituality and/or religiousness can manifest in a client?s life. 4. I discuss and clarify with a client their perceptions of spirituality and religiousness. 5. I can describe religious and spiritual beliefs and practices within a cultural context. 122 6. I understand the role religion/spirituality can play in various cultures as well as the role religion/spirituality can have in cultural development and personal cultural identification. 7. I work to develop an understanding of the potential interrelations between culture, religion, and spirituality. 8. I strive to understand specific spiritual/religious issues that may include personal examination or consultation with religious leaders or cultural experts. 9. I engage in self-exploration of my religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of my belief system. 10. I explore diverse religious/spiritual traditions and customs through reading, study and personal experience. 11. I reflect on and attempt to identify my internal motivations, counter-transference issues and potential biases toward diverse spiritual and/or religious beliefs and practices. 12. I continue to develop my own religious/spiritual issues such as spiritual identity, spiritual worldview, and relationship with the world, God, or higher powers. 13. I can describe my religious and/or spiritual belief system and explain various models of religious/spiritual development across the life span. 14. I can explain the role of religion/spirituality in my own life and worldview and how those views manifest in personal values and beliefs. 15. I understand and can explain how religious/spiritual development can progress across a life time and influence continuing development and growth. 123 16. I demonstrate sensitivity to and acceptance of a variety of religious and/or spiritual expressions in a client?s communication. 17. I encourage a client to be open about their religious and spiritual expressions. 18. I support a client?s experience and exploration of spirituality and religion through spiritual/religious expressions appropriate to their beliefs. 19. I can identify the limits of my understanding of a client?s spiritual expression and demonstrate appropriate referral skills and know general possible referral sources. 20. I understand and can explain my own limits of knowledge and experience as regards diverse religious and spiritual orientations. 21. I know when I have reached my own limits of knowledge, understanding and/or experience in understanding the religious/spiritual needs of a client. 22. I have the knowledge, experience and ability to use, appropriate referral sources that are congruent with a client?s belief system. 23. I can assess the relevance of the spiritual domains in the client?s therapeutic issues. 24. I explore with the client their presenting issues and the potential place their spiritual and/or religious beliefs and values have in those issues. 25. I explore with the client the resources (emotional, spiritual, cognitive, etc.) that they feel accompany their religious/spiritual values and beliefs. 124 26. I discuss with the client their perceptions of their own spirituality and/or religiousness with emphasis on the place of those perceptions in a client?s decision making or belief systems. 27. I am sensitive to and respectful of the spiritual themes in the counseling process as befits each client?s expressed preferences. 28. I strive to understand the place and importance of a client?s religious/spiritual values and beliefs in their worldview. 29. I explore the role of a client?s religious/spiritual values and beliefs in the creation and/or resolution of a client?s issues. 30. I explore the religious/spiritual beliefs of a client but refrain from introducing spiritual beliefs from outside the client?s expressed religious/spiritual orientation. 31. I use client?s spiritual beliefs in the pursuit of the client?s therapeutic goals as befits the client?s expressed preferences. 32. I explore with the client their preferred level of inclusion of religious and/or spiritual themes in the therapeutic process. 33. I integrate into the counseling process spiritual and religious components that are significant to a client. 34. I only use spiritual and religious components and practices that are accepted within a client?s expressed religious/spiritual orientation 125 Spiritual Competency Survey Demographic Questionnaire Please select, or type in, the response that best describes you. Please give only one response per item unless otherwise requested. 1. Please indicate your professional affiliation: (Please check one) Counseling Professional Psychology Professional Other (please briefly describe) 2. Are you currently licensed to practice in your professional field? Yes No ? 3. Are you currently practicing in your professional field? Yes No 4. Please identify your years of experience serving as a mental health provider. (Please check one) 0 ? 4 years 5 ? 9 years 10 ? 14 years 15+ years 5. What is your age? (Please check one) 21-30 31-40 41-50 51-60 61+ 126 6. What is your gender? Female Male 7. What is your racial/ethnic affiliation? (Please check one) African-American Asian/Pacific Islander Hispanic Multiracial Native American/American Indian/Alaska Native/First Nations White (Caucasian) Other (please describe) ?????? 8. What is your religion/spiritual affiliation? (if any) 9. What is the highest level of academic degree you have earned? Doctorate Educational Specialist. Masters (M.A./M.S./M.S.W./M.Div.) Other (please describe) 127 Appendix D Counselor Spiritual Competencies 1. A counselor should be able to explain the relationship between religion and spirituality, including similarities and differences. 2. A counselor should be able to describe religious and spiritual beliefs and practices within a cultural context. 3. A counselor should engage in self-exploration of his/her religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of his/her belief system. 4. A counselor should be able to describe his/her religious and/or spiritual belief system and explain various models of religious/spiritual development across the life span. 5. A counselor should demonstrate sensitivity to and acceptance of a variety of religious and/or spiritual expressions in the client?s communication. 6. A counselor should assess the relevance of the spiritual domains in the client?s therapeutic issues. 7. A counselor should be sensitive to and respectful of the spiritual themes in the counseling process as befits each client?s expressed preferences. 8. A counselor should use client?s spiritual beliefs in the pursuit of the client?s therapeutic goals as befits the client?s expressed preferences. 9. A counselor should identify the limits of his/her understanding of a client?s spiritual expression and demonstrate appropriate referral skills when necessary. 128 Appendix E Thematic Code of Counselor Spiritual Competencies Differentiation: The professional counselor can explain the relationship between religion and spirituality, including similarities and differences. ? An understanding on the part of the counselor of the potential similarities and differences between religion and spirituality. ? An understanding of the part of the counselor of how spirituality and/or religiousness can manifest in a client?s life. ? A discussion between the counselor and a client clarifying a client?s perceptions of spirituality and religiousness. Cultural Context: The professional counselor can describe religious and spiritual beliefs and practices within a cultural context. ? An understanding of the role religion/spirituality can play in various cultures as well as the role religion/spirituality can have in cultural development and personal cultural identification. ? An understanding of the potential interrelations between culture, religion, and spirituality. ? An investigation by the counselor of culturally specific spiritual/religious issues that may include personal examination or consultation with religious leaders or cultural experts. 129 Self-Awareness: The professional counselor engages in self-exploration of religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of diverse belief system. ? Exploration by the counselor of diverse religious/spiritual traditions and customs through reading, study and personal experience. ? An introspection of internal motivations, counter-transference issues and potential biases toward diverse spiritual and/or religious beliefs and practices. ? An understanding of, or ongoing process of finding, one?s own religious/spiritual issues such as spiritual identity, spiritual worldview, and relationship with the world, God, or higher powers. Religious/Spiritual Development: The professional counselor can describe her/his religious and/or spiritual belief system and explain various models of religious/spiritual development across the life span. ? An ability to explain the role of religion/spirituality in the counselors own life and worldview and how those views manifest in personal values and beliefs. ? An understanding of how religious/spiritual development can progress across a life time and influence continuing development and growth. Acceptance: The professional counselor can demonstrate sensitivity and acceptance of a variety of religious and/or spiritual expressions in client communication. ? Encouragement of a client to be open about their religious and spiritual expressions. 130 ? Support of client?s experience and exploration of spirituality and religion through spiritual/religious expressions. Assessment: The professional counselor can assess the relevance of the religious and/or spiritual domains in a client?s therapeutic issues. ? An exploration of the client?s presenting issues and the potential place their spiritual and/or religious beliefs and values have in those issues. ? An exploration of the resources (emotional, spiritual, cognitive, etc.) that a client feels accompanies their religious/spiritual values and beliefs. ? A discussion of a client?s perceptions of their own spirituality and/or religiousness with emphasis on the place of those perceptions in a client?s decision making or belief systems. Respect: The professional counselor is sensitive to and respectful of religious and/or spiritual themes in the counseling process as befits the expressed preference of each client. ? Understanding by the counselor of the place and importance of a client?s religious/spiritual values and beliefs in their worldview. ? An exploration of the role of a client?s religious/spiritual values and beliefs in the creation or resolution of a client?s issues. ? The counselor explores the religious/spiritual beliefs of a client but refrains from introducing spiritual beliefs from outside a client?s expressed religious/spiritual orientation. 131 Therapeutic Use of Beliefs: The professional counselor can use a client?s religious and/or spiritual beliefs in the pursuit of a client?s therapeutic goals as befits a client?s expressed preference. ? The counselor explores the client?s preferred level of inclusion of religious and/or spiritual themes in the therapeutic process. ? An integration into the counseling process of spiritual and religious components that are significant to a client. ? The counselor only uses spiritual and religious components and practices that are accepted within a client?s expressed religious/spiritual orientation. Limits of Understanding: The professional counselor can identify limits of her/his understanding of a client?s religious and/or spiritual expressions and demonstrate appropriate referral skills and general possible referral sources. ? An understanding of the counselor as to their own limits of knowledge and experience as regards diverse religious and spiritual orientations. ? An understanding of the counselor as to their own limits of knowledge, understanding and/or experience of the religious/spiritual needs of a client. ? A knowledge of, and ability to use, appropriate referral sources that are congruent with a client?s belief system. 132 Table 23 Survey Questions According to Domain Domain Survey Question Knowledge of religious and spiritual phenomena I can explain the relationship between religion and spirituality, including similarities and differences. I can describe religious and spiritual beliefs and practices within a cultural context. I understand the potential similarities and differences between religion and spirituality. I understand how spirituality and/or religiousness can manifest in a client?s life. I understand the role religion/spirituality can play in various cultures as well as the role religion/spirituality can have in cultural development and personal cultural identification. I work to develop an understanding of the potential interrelations between culture, religion, and spirituality. I strive to understand specific spiritual/religious issues that may include personal examination or consultation with religious leaders or cultural experts. I understand and can explain how religious/spiritual development can progress across a life time and influence continuing development and growth. (Table 23 continues) 133 Domain Survey Question Awareness of the mental health professionals? own spiritual perspectives I engage in self-exploration of my religious and spiritual beliefs in order to increase sensitivity, understanding, and acceptance of my belief system. I can describe my religious and/or spiritual belief system and explain various models of religious/spiritual development across the life span. I explore diverse religious/spiritual traditions and customs through reading, study and personal experience. I reflect on and attempt to identify my internal motivations, counter-transference issues and potential biases toward diverse spiritual and/or religious beliefs and practices. I continue to develop my own religious/spiritual issues such as spiritual identity, spiritual worldview, and relationship with the world, God, or higher powers. I can explain the role of religion/spirituality in my own life and worldview and how those views manifest in personal values and beliefs. I understand and can explain my own limits of knowledge and experience as regards diverse religious and spiritual orientations. (Table 23 continues) 134 Domain Survey Question Understanding of clients? religious and spiritual perspectives I demonstrate sensitivity to and acceptance of a variety of religious and/or spiritual expressions in a client?s communication. I am sensitive to and respectful of the spiritual themes in the counseling process as befits each client?s expressed preferences. I encourage a client to be open about their religious and spiritual expressions. I support a client?s experience and exploration of spirituality and religion through spiritual/religious expressions appropriate to their beliefs. I know when I have reached my own limits of knowledge, understanding and/or experience in understanding the religious/spiritual needs of a client. I discuss with the client their perceptions of their own spirituality and/or religiousness with emphasis on the place of those perceptions in a client?s decision making or belief systems. I strive to understand the place and importance of a client?s religious/spiritual values and beliefs in their worldview. I explore the religious/spiritual beliefs of a client but refrain from introducing spiritual beliefs from outside the client?s expressed religious/spiritual orientation. (Table 23 continues) 135 Domain Survey Question Religious and spiritually related interventions and strategies I can assess the relevance of the spiritual domains in the client?s therapeutic issues. I use client?s spiritual beliefs in the pursuit of the client?s therapeutic goals as befits the client?s expressed preferences. I can identify the limits of my understanding of a client?s spiritual expression and demonstrate appropriate referral skills and know general possible referral sources. I discuss and clarify with a client their perceptions of spirituality and religiousness. I have the knowledge, experience and ability to use, appropriate referral sources that are congruent with a client?s belief system. I explore with the client their presenting issues and the potential place their spiritual and/or religious beliefs and values have in those issues. I explore with the client the resources (emotional, spiritual, cognitive, etc.) that they feel accompany their religious/spiritual values and beliefs. I explore the role of a client?s religious/spiritual values and beliefs in the creation and/or resolution of a client?s issues. I explore with the client their preferred level of inclusion of religious and/or spiritual themes in the therapeutic process. I integrate into the counseling process spiritual and religious components that are significant to a client. I only use spiritual and religious components and practices that are accepted within a client?s expressed religious/spiritual orientation.