Clinical counseling Issues and applications for spiritual clients

Clinical counseling Issues and applications for spiritual clients Michele D. Aluoch River of Life Professional Counseling LLC www.rolpc.org (614) 353-4157

Incorporating Spirituality Into Core Counseling Courses(Briggs & Rayle, 2005) • Falls under the rubric of multicultural competencies and meeting the client where he/she is at • While most counselors recognize the value of having some awareness and training in the role of spiritual issues in counseling (60-90% in nearly all literature), very few (10-30%) state that it was any significant part of their coursework • “Spirituality” mentioned in CACREP standards for counseling programs • Falls under multicultural counseling domain in ACA Ethics- “Counselors must learn and acknowledge how their own cultural/ethnic, racial identities affect their attitudes and behaviors.” • AAMFT Code of Ethics: “MFTs provide assistance without discrimination on the basis of race, age, ethnicity, socioeconomic status, disability, gender, health status, religion, national origin”; “are aware of their influences”, ; “advance the welfare of the client”; “use appropriate services”

Incorporating Spirituality Into Core Counseling Courses(Briggs & Rayle, 2005) Questions For Clinical Counseling Students To Consider Regarding Their Own Spirituality: 1. What are your views concerning religion and spirituality? 2. How do you believe these views will affect your counseling role? 3. How will you be able to empathize with clients who have differing spiritual values than your own? 4. How will you keep your own spiritual values/beliefs from inappropriately influencing the counseling relationship?

Spirituality in Clinical Supervision (Tan 2007) • 1. Intervention skills • 2. Assessment approaches and techniques • 3. Individual and cultural differences • 4. Interpersonal assessment • 5. Theoretical orientation • 6. Problem conceptualization • 7. Selecting treatment goals and plans • 8. Professional ethics

A Christian Worldview Model of ClinicalCounseling Supervision (Bufford, 2007) • “worldviews are like sand- they get into everything” • How we interpret events, our rationales, why conflict, etc. • Saying or doing good and what blesses and encourages supervisees toward professional development • Speaking the truth in a context of Christian love • Correcting supervisees with an attitude of graciousness, kindness, gentleness, and humility remembering that we once were there • Accurately appraising ourselves • Being good stewards of the gifts and talents we have

Christian Worldview Model #2 of Clinical Counselor Supervision (Allen, Boyer, & Tucker, 2007) Supervisor as teacher: • 1. Assess supervisees spirituality/practices • 2. Provide resources to supervises for integrating spirituality with clients when appropriate • 3. Give supervises opportunity to assess client’s spirituality • 4.Give supervises feedback on their attempts at integration • 5. Show supervises how to use spiritually integrated interventions • 6. Offer ongoing instruction on use of Christian clinical models.

Christian Worldview Model #2 of Clinical Counselor Supervision (Allen, Boyer, & Tucker, 2007) Supervisor as facilitator: • 7. Help supervises differentiate between their own and their client’s belief. • 8. Encourage supervises to integrate spirituality into case conceptualization. • 9. Discuss with supervisees the client’s religious experiences in supervision. • 10. Use questions to spark discussion of religious an spiritual elements in cases • 11. Brainstorm which religious techniques could be used by supervises in sessions • 12. Identify religious transference and countertransference issues that may need to be addressed. • 13. Talk about refer to religious leaders when necessary. • 14. Encourage supervisees spiritual development.

Christian Worldview Model #2 of Clinical Counselor Supervision (Allen, Boyer, & Tucker, 2007) Supervisor As Model: • 15. Use parallel processes to show how to address spirituality and religious issues. • 16. Share self disclosures with supervisees. • 17. Role play Christian clinical counseling approaches in supervision. • Internal methods for supervisors: • 18. Introspection, examination, and refection • 19.Spiritual disciplines • 20. Involvement with a faith community • 21. Prayer for clinical supervision sessions • 22. Prayer for client situations.

Operational Definitions Exercise Exercises: Write definitions of: Spirituality Church Religion Heaven God Hell Spiritual development Spiritual maturity Mercy Justice

Developing An Awareness of Role of Spirituality in the Counselor’s Life • Narrative story about your spiritual journey (factors that shaped it, people/places, significant events, where you believe you are at today versus where you’d like to be/think God wants you to be, etc.) • Role play with different types of clients what it might be like to counsel a person from differing faith or spirituality beliefs. • Consider what a “holistic” approach means to you. What skills would you need to develop competencies to work with people of different ages, races, beliefs, religious, spiritual approaches?

Expectations of Conservative Christian Counseling Clients (Turton, 2004; Belaire, Young, Elder, 2005; ) • Expected respect for their worldview and acceptance • Expected that religion and spirituality would definitely be included as a significant part of the counseling process. May include (determine on a case by case basis): Moral teachings Scriptures or Bible verses Praying in Session Listening to story of their conversion or changes from past conversion, current struggles, etc. Hearing some thing about the counselor’s spiritual experience, moral beliefs, lifestyle, or conversion experiences Collateral consultation with clergy pastors, or religious “authorities” that the client can relate to or is accountable to Use “religious language” in session Use religious examples, stories, or parables Be willing to learn about client’s personal spiritual experience, denomination, journey. Refer client to someone who understands or can better empathically relate if n able to relate to it or understand or respect that Accept the religious practices and rituals that are part of client’s experience.

Expectations of Conservative Christian Counseling Clients (Continued) What Evangelical Christians Want From Counseling • Prefer Non Directive Approach • Expect to leave the counseling session with their lives “spiritually stimulated” • Expect to be encouraged to apply and further Biblical understanding • Goal of Counseling: Closer relationship with God, more fervent prayer life, a lifestyle that is consistent with traditional Biblical values, direct discouragement and challenging of lifestyle and behaviors inconsistent with the values they are stating they espouse • Overall: Less likely to attend counseling of the counselor is not a Christian and does not share their religious orientation (95%); Religious/spiritual beliefs affect my daily decisions (98%)

Why Spiritual Assessment?(Oakes & Raphel, 2008) • Enhances the counselor’s empathy and sensitivity toward the client’s unique experiences • Can support the counselor’s diagnosis about healthy or unhealthy spirituality • Can help the counselor identify outcomes that would be considered healthy spiritually for the client • Can help adapt counseling interventions personally to the spiritual needs and background of the client

Doing a Clinical Counseling Assessment Incorporating Spirituality(Richards, Bartz, & O’Grady, 2009)

Doing a Clinical Counseling Assessment Incorporating Spirituality 12 Sample Questions: 1. Do you wish to discuss spiritual issues in counseling when relevant? 2. Do you believe in God? 3. What is God to you? 4. Is spirituality important to you (scaling) 5. Do you have a religious affiliation? Imp.to you? (scaling) 6.Do you attend a church, synagogue, or another gathering place? 7. How closely do you follow the teachings of your religion?

Doing a Clinical Counseling Assessment Incorporating Spirituality 8. How do you experience God’s guidance in your personal life? 9. Are you aware of any spiritual resources or practice sin your life that could be used to help you cope with or solve your problem? What are they? 10. Anything about your spirituality or religious community that concerns you? 11. Would you like your counselor to consult with your spiritual/religious leader if this could be helpful to you? 12. Are you willing to consider trying religious or spiritualty based suggestions from your counselor if they could be helpful to you?

Doing a Clinical Counseling Assessment Incorporating Spirituality Level Two- Standardized Measures • Orthodoxy: How letter of the law and by the book a person is based on the traditional teachings of their religion • Spiritual Identity- The client’s sense of worth in relation to God • Level of Religious Commitment- extrinsic (to meet own ends) or intrinsic (internalized belief system) • God Image- The client’s perception of who God is • Value/Lifestyle Congruence- How consistent behaviors are with what client says he/she believes • Spiritual Well Being- Sense that life has meaning and purpose • Religious Problem Solving- 1) Self directing, 2) Deferring, 3) Collaborative

Doing a Clinical Counseling Assessment Incorporating Spirituality Effective Therapy • Not just about technique but about the therapist’s character and relationship with the client • About therapist’s individual and professional awareness and differentiation • Includes encouraging the client’s narrative of his/her spiritual journey

Doing a Clinical Counseling Assessment Incorporating Spirituality Questions To Facilitate Client’s Sharing Their Spiritual Narrative (Hoogestraat & Trammel, 2003) • How has your spirituality/religion influenced your life? • Tell me about God. • What does your spirituality mean to you? • Help me understand how you learned about spirituality/religion. • How do you think God view you? • Tell me about spiritual/religious traditions in your family. • How do you define spirituality/religion? • What spiritual/religious messages were handed down through your family? • Do you believe spirituality/religion causes more harm than good or more good than harm?

Doing a Clinical Counseling Assessment Incorporating Spirituality Questions For Cultivating A Spiritual Autobiography (Sociocultural Clinical perspective): • What is your earliest memory about God? • Were you raised in a religious family? What was that like? • What are your current religious views and beliefs? • How would you have described God when you were a child/teenager? • Who had the greatest spiritual or religious influence in you as a child/teenager? • What influenced your faith the most? • How would you describe your faith today? • What was your worst/best spiritual experience?

Doing a Clinical Counseling Assessment Incorporating Spirituality Spiritual Differentiation • Client or therapist identifying and describing self as separate as distinct from others, necessary for healthy emotional and spiritual development Higher differentiation associated with: • Greater capacity for intimacy • Allowing others to be themselves • Emotional stability • More open to discussing spirituality

Doing a Clinical Counseling Assessment Incorporating Spirituality (Answer these same spiritual autobiography questions about yourself) • What is your earliest memory about God? • Were you raised in a religious family? What was that like? • What are your current religious views and beliefs? • How would you have described God when you were a child/teenager? • Who had the greatest spiritual or religious influence in you as a child/teenager? • What influenced your faith the most? • How would you describe your faith today? • What was your worst/best spiritual experience?

Doing a Clinical Counseling Assessment Incorporating Spirituality Exercise: Developing Self Awareness & Differentiation as a Therapist What are your thoughts, views, beliefs on each of the following words? Can you counsel someone with differing views from your own? • Abortion • Death Penalty • Drinking/Drugs • R-rated movies • Premarital sex • Spanking or physical disciplining a child • Cohabitation • Pornography • Promiscuity • Domestic violence • Dancing • Piercings Etc.

Spirituality and Development of Self Identity (Griffith & Griggs, 2001) Four statuses: • 1) Diffusion- lack of interest in the spiritual, religion or who have a self-serving religiosity, may have had limited exposure to such or may view God as mean and unjust or nary • 2) Foreclosure- Learning to accommodate to the requests of others around you to gain acceptance and approval, obedience perspective • 3) Moratorium- Sincere self reflection and self examination, often through a time of great uncertainty which causes the person to re-evaluate things for self • 4) Achievement- internalized religious and spiritual beliefs, often based on a conversion experience, that which becomes a person’s core spiritual values

Spirituality and Development (Oakes & Raphel, 2008) • 1. Illumination- an awareness of possibilities • 2. Individualization- learning to esteem oneself, who am I? Who was I created to be? • 3. Separation- exploring and seeking answers to God questions • 4 Inspiration- A sense of purpose in life, reassessing how behaviors fit in with who I was called to be

Doing a Clinical Counseling Assessment Incorporating Spirituality • Differences between mental health professionals (e.g. Morrison, Clutter, Pritchett, & Demmitt, 2009; Walker, Gorsuch, Tan, & otis, 2008;Young, Wiggins-Frame, & Cashwell, 2007; Carlson, Kirkpatrick, Hecker, & Killmer, 2002): Only 25% of counselor educators deemed important to have classes on this ; very few social workers and psychologists- as little as 5-10% in some studies felt spirituality should ever be involved; 73 % of PCCs deemed important but felt not enough training; Highest percentages of training and involvement among marriage and family therapists- as much as 80-90%; Least concerned with spirituality personally or in sessions= psychologists (“80% never discussed with a client”- Walker et al.) • 86%of participants say spiritual training is important to develop competency in understanding dif. clients. • Only about 25% or less of mental health professionals in most surveys received any integration of spiritual/religious issues into their counseling training programs • In the counseling literature of social workers, psychiatrics, psychologists, marriage and family therapists, & counselors on surveys done in the last 10 tens asking clients “is spirituality important to your emotional healing showed 70-98% of those per survey said ‘yes’ with most percentages around 80-85% in secular and medical settings even and 85-98% among those specific requesting Christian/spiritual counselors

God Images and Processing Counseling Concerns (Peloso) • The culture of a client’s spiritual/religious/God experience • Meeting the client where he/she is at may involve understanding the language, images, and ritual by which they experience God • Process Of Incorporating God Images: • 1) Conscious conflict- noticing difference between what I was taught and what I seem to be experiencing • 2)Time of Pause- Evaluating the contradiction • 3) Image/insight- coming up with some explanation or insight to explain the contradiction • 4)Repatterning/reframing- recomposing meaning • 5) Interpretation on dialogue- new insight about one’s spiritual image

God Images and Processing Counseling Concerns (Peloso) • Definitions Of God Image Love---------22 Creator----------21 Always Present-----------20 Friend-----------16 Jesus Christ----------11 Strength------------11 Peaceful------------11 • (Others: comfort, support, forgiving, a guide, compassionate, patient, a mystery, a spirit, powerful, etc.) • (Asses client’s definitions and experiences; Don’t assume or base on your experiences or God concept

God Concepts Based on Childhood Experiences (Dickie, Ajega, Kobylak, Nixon, 2006; DeRoos, 2006) • For both men and women mother or father nurturance led to self esteem or self reassurance • Differences- Girls whose parents used power oriented discipline (yelling, threatening, spanking) saw themselves, parents, and God as less powerful and less nurturing but for boys power-oriented discipline was not related to self, parent, and God concepts. • In disruptive homes young children learn God to be a comforter and helper but they struggle with God as intimate and personal to them.

Spiritual Genograms (Willow, Tobin, & Tomer, 2009) • For self reflection, understanding of spiritual and religious practices and family systems and multi-generational dynamics • Charting a spiritual family tree

Rational Christian Therapy(Johnson, 2006) • Using proven REBT- Rational Emotive Behavior Therapy (Albert Ellis) but incorporating client belief systems and spiritual worldview

Rational Christian Therapy(Johnson, 2006) • Using proven REBT- Rational Emotive Behavior Therapy (Albert Ellis) but incorporating client belief systems and spiritual worldview Common Thinking Errors: 1. Awfulizing- ____ is awful, terrible, catastrophic or as bad as it could possibly be. 2) Low Frustration Tolerance- I can’t stand _____; _____ is too much and is intolerable or unbearable. 3) Self Downing- I am no good, worthless, useless, and utter failure, beyond hope or help, devoid of value. 4) Other downing- You are no good, worthless, useless, an utter failure, beyond hope, of no value 1) But God can never separate us from His love, Romans 8:39 2) But those who endure are called blessed, James 5:11 3 & 4) But my/others’ sin does not determine me to be a worthless person the rest of my life. I can change and turn around if not by my will power by God’s grace. My life is still meaningful and significant, Titus 3:4-7

Rational Christian Therapy(Johnson, 2006) Common Misbeliefs in the Counseling Literature: • God must answer my prayers as I’d like them to be answered. • I absolutely should always be loved unconditionally by all my fellow churchgoers/Christians. • I ought to undeniably be obeyed by other when I quote Scriptures to defend my position. • I must never be judged but totally accepted as I am. • I must always be judged • If only I work hard “enough” then God will see that I deserve _____. • Good people should always have “good” things happen to them and “bad” people should have “bad” things happen to them. (justice perspective) • People should have mercy on me but they should get what they deserve (justice). • I must spend the rest of my life paying back for what I said, did, etc.

Beliefs Of Conservative Christians That May Clash with Traditional Counseling (Eriksen, Marston, & Korte, 2002) Five Common Belief Systems of Conservative Christians to be Aware of in Counseling: • 1) Self- focusing on oneself is selfish and is a sin • 2) Truth- Christianity is the only true way to God • 3) Answers to problems- the Bible is the answer book • 4)Feelings-joy and peace are only acceptable • 5) Social issues- divorce, homosexuality, abortion are not to be participated in • How would you handle someone who possibly espouses any of these beliefs?

Cognitive-Behavioral Therapy Incorporating Prayer and Scripture (Tan, 2007) • Do the level one assessment suggested earlier to get spiritual background • Incorporate prayer and Scripture when appropriate • When Beneficial to client • With consistency in their worldview and self talk

Solution-Focused Counseling For Clients With Spiritual Concerns (Guterman & Leite, 2006) • Focuses on the interpersonal exchange • Goal- Increasing the number of exceptions to the problem: Observations of times clients are without the problem, observations of times where the problem is more resolved (client as expert observer in his/her world) • What treatments are effective for whom and under what circumstances” • Helpful questions: • Was there a time you coped better? • How did you manage? • The miracle question • Consistent with Christian spirituality: God intervening from the future to impact the present & humans as agents in collaborative partnership with God (Frederick, 2008)

Clinical Counseling Versus Spiritual Direction (Sperry, 2003) • NOT the same SPIRITUAL DIRECTIONCOUNSELING Spiritual assessment Psych Assessment (may include spiritual history) Spiritual experience, DMS IV diagnosis- may be psychopathology not psychopathology Spiritual Transformation Symptom reduction, Increased functioning, Personality/Character changes Triadic Rel. Improvement Dyadic Therapeutic Alliance Direct Advisement Therapeutic Interventions Discernment Mutual collaboration Spiritual Resistance Psychological Resistance

Dealing With The Spiritual Issue of Diminished Hope and Purpose (Jones, 2009) • “taking people to the healing waters”, “Do you want to be healed?” • Key Questions: “What hurts?”, “What heals?” Steps: • 1. perceiving • 2. compassion for the client’s story • 3. reaching out to the hurting person • 4. asking clarifying questions • 5. engaging the will- drawing on the client’s resources/strengths? • 6. embracing the client’s stuckness • 7. encouraging connectedness- behavioral goals to help the client get connected to what is spiritually uplifting for him/her

Attachment Theory and Spirituality (Reinhert, Anderson, Lewis-Hall, & Hall, 2010; Reinhert, Edwards, & Hendrix, 2009; Joung, 2006) • Secure or insecure • Often interactions with significant caregivers/guardians lay a foundation for how people see God as attachment figure (similar or directly opposite) • Correspondence hypothesis- if a person’s attachments growing up were secure they will be securely attached to God • Compensation hypothesis- A person tries to redo or undo unhealthy attachment issues with a relationship with God

The Healing Cycle: Christian Group Therapy (Hook & Hook, 2010) Steps in group therapy: • Grace, Safety, Vulnerability, Truth, Ownership Grace- all need to know God’s unconditional love kindnes who acknowledge their need fro Him. • Group members model the heart attitude of comfort, mercy in the face of brokenness • I what ways have you experienced the grace of God in the midst of your brokenness? • In what ways have you experienced grace from others? • What are some of the barriers you faced? How did you work through them?

The Healing Cycle: Christian Group Therapy (Hook & Hook, 2010) • Safety- Freedom from fear anxiety, and apprehension as group members open up • Knowing that each group member can share vulnerable info. and it will be safe within the group (confidentiality, lack of judgment, each doing own work, pass if you want, consistent attendance and commitment to the group) • Boundaries- clear expectations

The Healing Cycle: Christian Group Therapy (Hook & Hook, 2010) Vulnerability- Self disclosure, listening, and validation • Sharing and risk taking for the benefit of the group • Accessing feelings in session so that group members together can carry each other’s burdens Truth- What God says about the situation, hearing input for others • Key- speaking truth in an attitude of love rather than one which produces increased hurt and damages more Ownership- responsibility for each one’s own part in healing process • Includes telling the whole story, reducing blame on others, and refocusing on personal solutions

Christian Clients’ Preferences About Prayer In Counseling (Weld & Eriksen, 2007) • 82% wanted audile prayer in session • Most wanted the therapist to broach the subject of whether spirituality is important in counseling and what that includes • Religious conservatives expected prayer more often and regularly compared to others • Studies that prayer can increase a sense of emotional well being in those who advocate it • Is prayer appropriate?: Only 11% in secular agencies compared with 78% in Christian agencies and 100% in Christian private practices

Christian Clients’ Preferences About Prayer In Counseling (Weld & Eriksen, 2007) • “If we don’t let clients know that we are willing to talk about their spiritual lives if thy feel it would be helpful to therapy, then what we don’t say is in effect telling them that it is not okay to talk about these things.”

Prayer in Clinical Counseling(Weld & Eriksen, 2007) Prayer showed statistically significant results in areas of conflict resolution: • Softening • Developing a healing perspective • Changing responsibility

Narrative Approaches to Counseling(Pembroke, 2005) • Reconceptualizing problem-bound stories • Helping the client re-assemble unique alternative outcomes • Helping the client make the new alternative endings and strong and as possible as the problem bound ones • Partnership in the story between the client, the counselor, and the support system (affirmation strength, strengthening)

Family Therapy ( Walsh, 2010; Gostenick, Repic, & Cvetek, 2008) • 85% call self “religious” • 44% have changed backgrounds from upbringing • Over 60% are part of a congregation yet only 38% attend weekly • Very significant for African-Americans • Latinos often strongly involved in Catholicism although more turning to Pentecostal and Charismatic churches for direct spiritual experiences, emphasis on tradition with dead relatives • Latin Americans, Africans, and Asians- spirituality is significant to daily life • Potential Areas to Assess and Address (frequent systems concerns): • Interfaith marriage, child rearing, death and loss, rituals and traditions or practices, connectedness with nature, involvement with creative arts, involvement with social activism • Gaps between belief and practice- e.g Over 90% of American homes have a Bible but 58% of Americans cannot name the Ten Commandments and do not know who the 12 Apostles are • NOTE: Can use similar questions regarding above areas and self and meaning in life with atheists.

Christian Approach For Mood Disorders (Hankle, 2010) • A narrative and journaling approach using the Psalms • A means to process emotions, including the unpleasant ones (anger, questions, doubt, depression, anxiety, etc.) • Giving voice to internal concerns Format: Feeling, questions, BUT pos. self message Emotions spiritual resources, faith statement

Spiritual Approaches in Counseling that Highly Religious Clients Said Were Helpful (Martinez, Smith, & Barlow, 2007) • Reference to Scripture • Therapist keeping them in prayer privately • Religious/spiritual assessment • Religious/spiritual self disclosure • Religious/spiritual imagery • Religious/spiritual confrontation • Therapist/client prayer in session • Encouraging forgiveness

Spiritual Approaches in Counseling that Highly Religious Clients Said Were Helpful (Martinez, Smith, & Barlow, 2007) • Supporting client involvement in religious community • Client prayer at home • Religious bibliotherapy • Encouraging client confession • Spiritual journaling

Clinical counseling Issues and applications for spiritual clients