LockStudents in counselor education courses often ask what special training they need to counsel clients with spiritual issues. I ask these students to consider what course content, prior employment, life experience or other education might prepare them to address religious or spiritual themes. Some report they would rely on pastoral training or personal experiences in specific religious denominations. Others mention required diversity courses but are unsure whether all of the world religions can be covered properly in depth. A few students note self-perception of religious experiences (both healthy and unhealthy) and wonder about imposing values.

I usually follow up these students’ comments by posing the same question about different presenting problems. What specialized training might they need to assist clients with communication issues, addictions, sexual dysfunction or anxiety? The room always goes silent as they ponder the true nature of my question. Some diagnoses — for example, eating disorders and personality disorders — are so difficult to treat that they require specialized training even after obtaining a master’s degree. But the perception that religious or spiritual issues are somehow different than most other presenting problems limits clinical engagement in this important aspect of well-being.

Graduate students in the mental health field gradually develop knowledge and skills that can lead clients with unhealthy thoughts, behaviors and emotions toward change. New counselor education graduates are not expected to be experts immediately. Rather, they experience tremendous professional growth during their prelicensure, supervised experience. The students’ concern over their level of religious or spiritual expertise challenged me to consider what expectations I convey as an educator. Furthermore, I wondered why the question about spiritual expertise arose so often in comparison with the other topics counseling students study.

Those classroom discussions and the questions that followed led me to conduct four years of empirical research. In my research, I evaluated the content taught in CACREP-accredited institutions as compared with that of private, religious-based programs; the differences between what educators in private, religious-based programs thought they were teaching
and what the students reported being taught; and master’s-level students’ perceptions of a transcendent other as related to attachment style.

On the basis of these and other studies, in addition to an extensive literature review, awareness of pedagogical assumptions about counselor education and student anecdotes, the Spiritual Integration Toolbox was born. As a former steel fabricator with years of project management experience, the toolbox seemed an apt metaphor. The conceptualization of specific counseling skills and knowledge as tools helps me to convey their importance in a unique way.

Intake and assessment

Religion and spirituality (RS) are important dimensions in counseling regardless of the presenting problem. RS issues may or may not be addressed in treatment depending on stated client goals, but information about RS should be collected upon intake just as clinicians collect information on sociodemographics, family history, development, attachment, symptoms, mental health history, medical information, educational experiences, career background, legal issues and social relationships. Proper use of spiritual integration tools assumes:

  • Basic knowledge of the differences between religion and spirituality
  • An awareness of ethical and legal responsibilities to incorporate client RS concerns in assessment, diagnosis and treatment planning
  • A general understanding of the potential harm to clients when clinicians impose their own values

The first requirement for integrating spiritual issues into counseling is the choice of toolbox: a proper RS intake. Intake is a facilitated process rather than a product, and it helps carry the clinician’s understanding of client RS history throughout the clinical relationship. Much like a portable toolbox that carries integral tools from a larger tool chest, specific RS questions should be chosen to elicit discussion about RS experiences and changes, familial or relational pressure, trauma or abuse (all types), influence of RS cultural identity, self-awareness, image of a transcendent other, perception of a relationship with a transcendent other, and current feelings, cognitions and behaviors.

Clinical assessment is the most complicated tool in the box. Its use will be limited by how much research clinicians want to conduct and how much training clinicians receive before using it. These assessments function as a level in a clinician’s toolbox. Contractors know that levels can be used to determine grades and elevation changes, turn rough angles, lay out building foundations, set forms, level walls, and set lines and stakes. Likewise, specific RS assessments allow clinicians to balance qualitative RS information collected via verbal or written intake with valid and reliable empirical data. A variety of valid and reliable RS assessments can measure attitudes, beliefs, engagement, satisfaction, maturity, wisdom, knowledge or confidence in particular faith systems, as well as how RS issues affect clients relationally and how the image of a transcendent other relates to attachment.

For example, John Ingram and Ed Sandvick’s Holy Spirit Questionnaire (1994) was designed to measure perceived knowledge of the Holy Spirit. This tool helps assess client content, language and perception. Craig Ellison and Raymond Paloutzian developed the Spiritual Well-Being Scale (1982) to assess the spiritual dimension of the subjective state of well-being, including vertical and horizontal dimensions. The vertical dimension refers to a sense of well-being in relationship to God. The horizontal scale is the overall sense of life purpose and satisfaction.

Lest clinicians assume assessment tools are available only for clients of the Christian faith, Todd Hall and Keith Edwards designed the Spiritual Assessment Inventory (1996) to measure five spiritual maturity factors: awareness, realistic acceptance, disappointment, grandiosity and instability. Internal consistency is high and construct validity is good. This instrument also contains a lie scale.

The Francis Scale of Attitude Toward Christianity (FSAC, 1978) measures attitudes on religious values. Its items emphasize a unidimentionality of religion rather than focusing on religious lifestyle behaviors such as worship attendance. Therefore, there is evidence that the scale is valid and reliable in measuring attitudes toward Christianity, Hinduism, Islam and Judaism. Phra Nicholas Thanissaro’s amended FSAC (2011) demonstrated internal consistency, reliability and validity with Buddhist and Sikh populations.

Kim Bartholomew and Leonard Horowitz designed the Relationship Scale Questionnaire (1991) to evaluate orientation to close relationships, noting that the language of each of the 30 items could be reworded to suggest a specific type of relationship such as significant other or relative. In 2010, David Manock and I amended the items for RS assessment by changing the stems to read transcendent other. We found strong reliability and validity, internal consistency, construct validity across a variety of faith systems and also correlation to attachment style. Using an assortment of these types of instruments will add depth to the clinician’s understanding of client RS concerns.

Diagnosis and treatment planning

What happens after all this assessment?

My husband likes to work on cars in his spare time. He keeps a tool in his portable toolbox that reads engine codes. Those codes help him identify problems noted by the car’s computer system and tell him what parts to repair or replace. Similarly, diagnostic codes enable clinicians to identify specific symptoms and determine the course and prognosis of specific illnesses and issues. Understanding which diagnostic codes in the Diagnostic and Statistical Manual of Mental Disorders (DSM) correlate most often with RS issues hones the clinician’s focus.

Diagnosis related to RS issues can be made using a V code for religious or spiritual problems alone, as a complication to other diagnoses or as a comorbid disorder. Thus, problems or concerns related to RS issues should be diagnosed using the V code and then addressed in treatment planning. Pay close attention to the possibility of comorbid or co-occurring disorders. Research has demonstrated correlation in both diagnosis and treatment between RS problems and posttraumatic stress disorder (PTSD), addictions, sexual dysfunction and disorders, mood disorders (specifically major depressive episode and the postpartum subtype), anxiety disorders, sleep disorders and bereavement.

Once diagnosis occurs, accurate treatment planning takes priority. Contractors rely on guides called construction masters when tackling building projects (though the texts are often found on the floorboards of trucks rather than in toolboxes). These guidebooks detail the correct way to accomplish tasks, from determining proper rise and run of stairs to measuring the amount of concrete necessary to pour a pad. There are many right ways to design treatment plans, but certain key elements must be present: collaboration with clients in establishing goals, alignment of interventions and homework with measurable outcomes, and continuity throughout. Continuity means the client’s report of symptoms relates to diagnostic criteria. Diagnostic criteria lead clinicians to a diagnosis and prognosis. Proper diagnosis and understanding of prognosis lead to relevant goal setting. Relevant goals lead to accurate choice of interventions. Accurate interventions lead to clear outcome measures. Clear outcome measures lead to awareness of effectiveness. Awareness of effectiveness leads to engaging and dynamic treatment. This type of evidence-based continuity in treatment planning is what I term elegant design.


Imagine designing the most elegant treatment plan possible and then getting to the intervention column without the tools to facilitate the RS changes necessary for client growth. So far, you have chosen a nice toolbox (intake), included a level (assessment instruments), and referred to your construction master (the DSM). Interventions are the remaining tools that clinicians use to effect change — to do the work of counseling. Clinicians need a full bag of tools, yet they often get stuck when designing interventions because they confuse pastoral counseling with counseling for RS issues. Pastoral counselors concern themselves with spiritual growth within a specific religion in addition to overall mental health. The inclusion of RS issues in counseling assumes that spiritual growth may occur as mental health improves, but it does not limit the client to growth consistent within a specific faith system or religion.

Furthermore, useful RS interventions assess the psychology of RS experiences rather than the rightness or wrongness of spiritual beliefs. Thus, most clinical interventions can be adapted for RS issues. The types of interventions most researched include:

  • RS prayer, meditation or centering (compass)
  • RS reading or film review
  • Teaching RS concepts related to well-being as presented in existing literature, such as the differences between religion and spirituality (how-to manuals)
  • RS engagements and activities
  • RS journaling and writing assignments (screwdriver)
  • In-session confrontation or challenge about incongruent RS beliefs (hammer)
  • Exploration and adjustment of RS language and concepts (wrench)
  • Review of attachment images related to RS experience
  • Projective techniques (laser)

Interventions for RS issues should be related directly to the client’s presenting problems, stated goals, interests or complications affecting success in treatment. As with all interventions, they should be utilized in service toward improving treatment outcomes.

Case study

Now comes the fun part — application. Rosa is a 27-year-old Hispanic female working in retail sales in a big box store. She presents for individual counseling for PTSD symptoms 10 months after the death of her twin sister in a car accident. Although the accident was not Rosa’s fault, she was driving when the accident occurred. She was seriously injured and could not attend her sister’s funeral. Rosa reports experiencing hypervigilance, nightmares, hopelessness, depersonalization, an impending sense of doom and flashbacks since she awoke in the hospital after the accident. She says she feels “guilty about everything,” from her sister’s death to misplacing simple items at work or home. She also states she “is angry at God for taking her sister” rather than taking her or both of them.

Regarding family history of mental illness, Rosa says she is unaware of any diagnosis on either side or her family. She reports, however, that her mother behaved as though she were depressed and neglected Rosa and her siblings. Indeed, Rosa describes living in a multigenerational household and caring for her elderly grandparents and younger siblings because her mother was often absent without explanation. Rosa’s father was never involved in her life. Rosa also describes some enmeshment between her and her twin sister, saying they still dressed the same way up until the accident. Rosa reports relying heavily on her twin for emotional support after experiencing a date rape at age 16. She states, “My sister protected me, kept men away for years and recently began choosing men for me to date to help me get past the assault.”

Prior to the accident, work and career boosted Rosa’s self-esteem. She had succeeded in school despite years of academic struggles after being diagnosed with dyslexia at age 14. She worked her way up to department management at her store in only four years but reports concern that she will now lose her job because of excessive absences and scenes she has created recently at the store. She acknowledges having several “panic attacks” and screaming in terror after being startled by a loud noise or a customer approaching her from behind.

Rosa describes her Catholic faith as “foundational” in her development but states, “I refuse to go to church anymore.” Although she admits feeling guilty about that and “missing my church family,” she reports feeling angry with God. She also describes having “my own version of religion.” She explains that multiple friends videotaped her sister’s funeral and created a montage of video clips for her. While watching the video almost daily, Rosa prays and talks to her sister, asking her for guidance and advice. Her stated goals in counseling include a reduction of “panicky feelings,” a sense of control over her hypervigilant behaviors, a decreased sense of guilt, and restoration to and relationship with her faith and church family.

In addition to this verbal intake information, Rosa completed the Spiritual Well-Being Scale, the Spiritual Assessment Inventory and the modified Relationship Scale Questionnaire. These instruments confirmed and detailed attachment issues projected onto Rosa’s image of God, her sense of abandonment and fear of intimate relationships, all related to RS experiences. Rosa was diagnosed with PTSD, bereavement and religious or spiritual problems. Among other interventions, treatment included:

  • Repeated use of the Instant Calming Sequence (ICS) for centering and relaxation to reduce anxiety (later supplemented with prayer)
  • Client journaling about feelings of panic to identify triggers
  • Projective techniques using play dough and sand tray to identify and express issues of attachment, shame and guilt
  • Step-by-step reengagement in faith-based activities that encouraged feelings of safety and socialization

Robert Cooper designed the ICS (2003) as a six-step process to help change the brain’s and body’s reaction to stressful situations. The six steps seem simple, but when practiced consistently, they provide clients with a sense of control over anxiety symptoms. The steps are controlled breathing, smiling, positive posture, relaxation, facing reality and taking control.

The prognosis for treatment of PTSD alone is challenging because Rosa waited 10 months before seeking treatment. Furthermore, when issues regarding social support, childhood neglect, family history of mood disorder, and preexisting trauma complicate PTSD, full remittance of symptoms is unlikely. Thus, identifying all comorbid diagnoses is important for Rosa’s treatment. Helping Rosa through RS issues and bereavement is necessary for reduction of PTSD symptoms if full remission is not possible.

Rosa’s willingness to engage in projective RS interventions seemed key to her success. They allowed her to examine how misperceptions embedded by her young experiences and absence of attachment interfered with her image of God. She chose to work hard to create new relationships within her chosen faith system, which were healthier examples than what she was exposed to during her youth. These healthier social relationships provided much-needed emotional support and also allowed her to understand her enmeshment with her sister. Once she understood and released her unhealthy reliance on her twin, she was able to grieve, unencumbered by the idolization that previously had buried her in guilt. Though some flashbacks, sleep disturbance and sensitivity to sound triggers still exist, Rosa reports feeling safe and having hope for the future. She is even dating again.

Effective treatment for RS issues is not reliant upon religious knowledge, theological training or years of engagement in a particular faith system. Indeed, too much knowledge can often become a barrier in treatment when clinicians begin to feel expert about RS issues. Rather, a willingness to evaluate the psychological impact of RS experiences — to fully engage in the client’s RS world — allows clinicians to conceptualize how RS issues become embedded in other symptoms and diagnoses. Identifying and treating RS issues can enhance clinical work and promote holistic healing. The Spiritual Integration Toolbox is simply a reminder that clinicians already have the tools necessary to do this important work.


Knowledge Share articles are adapted from sessions presented at American Counseling Association conferences.

After six years of teaching in counselor education at George Fox University and a year as the director of Student Health and Counseling at Western Oregon University, Michelle J. Cox is currently home on leave caring for her terminally ill husband. She provides mental health consulting services online to individuals, families and organizations seeking to integrate medical, mental health and spirituality into holistic treatment planning for those struggling with mental illness. She spends ample time writing and recording the progression of her husband’s early-onset dementia and its impact on the family. She is also training their three Australian shepherd puppies to become therapy and service dogs for her husband. Contact her at MichelleJCoxphd@gmail.com.


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