Bringing Religion and Spirituality Into Therapy: A Process-Based Model for Pluralistic Practice 2019006305, 2019006844, 9781351030540, 9781138476455, 9781138476479

Table of contents :
Cover
Half Title
Title
Copyright
Dedication
Contents
List of Illustrations
1 Introduction
2 Ways of Understanding
3 Ways of Being
4 Ways of Intervening
5 Assessment and Case Formulation
6 Diversity
7 Ethics
8 Learning From Research
9 Competencies and Education
10 Epilogue
Index

Citation preview

“Bringing Religion and Spirituality Into Therapy offers a practical approach to equipping mental health care providers with the rationale and tools needed to integrate clients’ religion/spirituality into therapy. I highly recommend that any helping professional engaging in mental or behavioral health assessment and treatment add this title to their bookshelf.” — Holly K. Oxhandler, PhD, LMSW, associate dean for research and faculty development at Baylor University’s Diana R. Garland School of Social Work “Bringing Religion and Spirituality Into Therapy moves the discussion of religious and spiritual issues to new and exciting heights. It is a truly integrative approach, which is exactly what mental health students and therapists need for highly effective practice. It is hard to imagine practicing confidently with very diverse clients without this paradigmshifting book.” — Len Sperry, MD, PhD, author of Spirituality in Clinical Practice: Theory and Practice of Spirituality Oriented Psychotherapy, 2nd ed. “Unique in their focus, Stewart-Sicking, Fox, and Deal eloquently and artfully weave together the process of spiritually integrated therapy, highlighting a path that deeply values and respects clients with diverse developmental levels, belief systems, practices, and experiences. This is a brilliant how-to guide for clinicians new and seasoned alike.” — Craig S. Cashwell, PhD, LPC, NCC, ACS, professor and chair of the Department of Counseling and Educational Development, University of North Carolina Greensboro

Bringing Religion and Spirituality Into Therapy

Bringing Religion and Spirituality Into Therapy provides a comprehensive and timely model for spirituality-integrated therapy which is truly pluralist and responsive to the ever-evolving world of religion/spirituality. This book presents an algorithmic, process-based model for organizing the abundance of theoretical and practical literature around how psychology, religion, and spirituality interact in counseling. Building on a tripartite framework, the book discusses the practical implications of the model and shows how it can be used in the context of assessment and case formulation, research, clinical competence, and education, and the broad framework ties together many strands of scholarship into religion and spirituality in counseling across a number of disciplines. Chapters address the concerns of groups such as the unaffiliated, non-theists, and those with multiple spiritual influences. This approachable book is aimed at mental health students, practitioners, and educators. In it, readers are challenged to develop richer ways of understanding, being, and intervening when religion and spirituality are brought into therapy. Joseph A. Stewart-Sicking, EdD, is professor of education specialties at Loyola University Maryland and an Episcopal priest. Jesse Fox, PhD, serves as an assistant professor at Stetson University and taught pastoral counseling at Loyola University Maryland. Paul J. Deal, PhD, NCC, is an assistant professor of counselor education at SUNY Plattsburgh.

Bringing Religion and Spirituality Into Therapy A Process-Based Model for Pluralistic Practice Joseph A. Stewart-Sicking, Jesse Fox, and Paul J. Deal

First published 2020 by Routledge 52 Vanderbilt Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2020 Joseph A. Stewart-Sicking, Jesse Fox, and Paul J. Deal The right of Joseph A. Stewart-Sicking, Jesse Fox, and Paul J. Deal to be identified as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Names: Stewart-Sicking, Joseph, author. | Fox, Jesse (Of Stetson   University), author. | Deal, Paul J., author. Title: Bringing religion and spirituality into therapy : a process-based   model for pluralistic practice / Joseph A. Stewart-Sicking, Jesse Fox,   and Paul J. Deal. Description: New York, NY : Routledge, 2019. | Includes   bibliographical references and index. Identifiers: LCCN 2019006305 (print) | LCCN 2019006844 (ebook) |   ISBN 9781351030540 (eBook) | ISBN 9781138476455 (hardback) |   ISBN 9781138476479 (pbk.) | ISBN 9781351030540 (ebk) Subjects: | MESH: Counseling—methods | Mental Health   Services | Religion and Psychology | Spirituality Classification: LCC RC466 (ebook) | LCC RC466 (print) | NLM   WM 55 | DDC 362.1/04256—dc23 LC record available at https://lccn.loc.gov/2019006305 ISBN: 978-1-138-47645-5 (hbk) ISBN: 978-1-138-47647-9 (pbk) ISBN: 978-1-351-03054-0 (ebk) Typeset in Sabon by Apex CoVantage, LLC

Dedication—For the faculty, staff, students, and alumni of the Department of Pastoral Counseling, Loyola University Maryland. O du verlorener Gott! Du unendliche Spur! Nur weil dich reißend zuletzt die Feindschaft verteilte, sind wir die Hörenden jetzt und ein Mund der Natur. —R. M. Rilke, Sonnets to Orpheus I, 26 (O you lost God! You unending path! Only because enmity finally divided you, torn apart, are we now hearers and a mouth of Nature.) [Authors’ own translation]

Joseph A. Stewart-Sicking—For Megan, Sam, and Simon. Jesse Fox—For Amanda, Jaden, Iker, and Marco. Your inspiration for this book is everywhere present. Paul J. Deal—For all my teachers of dialogue; particularly Ruth and Dale.

Contents

List of Illustrationsx  1 Introduction

1

  2 Ways of Understanding

22

  3 Ways of Being

48

  4 Ways of Intervening

72

  5 Assessment and Case Formulation

97

 6 Diversity

130

 7 Ethics

154

  8 Learning From Research

180

  9 Competencies and Education

203

10 Epilogue

224

Index228

Illustrations

Tables 2.1 5.1 5.2 5.3 5.4 6.1

Examples of Psychospiritual Themes Case Formulation The Ways Paradigm for Assessment of Client Hector The Ways Paradigm for Assessment of Client Elissa The Ways Paradigm for Assessment of Client Zadie R/S Identity Status in Clients and Clinicians

40 98 117 120 122 133

Box 3.1 Ways of Being Reflection

68

Figures 8.1 Theoretical Diagram of Mediation 8.2 Theoretical Diagram of Moderation

194 195

1 Introduction

Learning to be a therapist is not just an academic challenge. No matter how strong we are as students, internships often confront us with situations that slip between the cracks of what we learned in class. Working with student interns can make this abundantly clear. For example, consider the experience of one intern, a committed evangelical Christian who hoped to enter faith-based counseling, meeting his client, Lillian. Lillian was a 27-year-old, second-generation Chinese-American woman seeking counseling for symptoms of depression. During the initial intake, she had focused on problems related to her meaning and purpose in life that had become very intense after caring for an ailing grandparent. Layered amid her feelings of grief and loss, Lillian recalled being struck by the quiet serenity her grandmother exuded, particularly during her final weeks. Now she was wondering about her own capacity to feel at ease. In discussing where she was finding meaning, Lillian described herself as having no formal religious upbringing and being an atheist for most of her life. Her parents were raised through the Cultural Revolution in which traditional religion was suppressed, and upon immigrating, they embraced secular humanism. Additionally, much of the Christian tradition she had been exposed to through American culture seemed unconvincing and irrelevant to everyday life. However, more recently, she had found her perspective changing after several experiences while camping in which she felt a deep sense of awe and connection with the natural world. She had never been able to describe adequately what those experiences meant for her, but simply noticed that during them she felt less depressed and more energized. Upon a recommendation from a friend, Lillian had recently begun practicing mindfulness meditation. She said that she hadn’t thought of it as particularly spiritual, but out of curiosity she had started reading some books on Zen Buddhism recommended by her friend. She really liked them, and they made her think about meditation in new ways. Knowing that her grandmother was, at least, influenced by Buddhism, Lillian was feeling as though she may be on a path not only to cultivating her own sense of serenity, but to deepening a connection with her beloved, and now deceased, grandmother.

2 Introduction Lillian did not have an unusual problem, and she fit into multiple categories of diversity training, but she still gave the intern pause. Was it OK to label her meaning-making process “spiritual”? If he opened the possibility of talking about spirituality, what parts of her spirituality were OK to focus on in therapy, and which could be useful for interventions to help her cope? Should he encourage her to explore Buddhism more? And if so, how much did he need to learn about Buddhism? How should he monitor himself for countertransference with someone whose experience and commitments were so different than her own? The intern said he had been anxious to engage clients’ spiritual and religious resources in therapy, but when the client’s identity was so different, he wasn’t sure what it was ethical to do, especially since he was working in a secular clinic.

The Spiritual and Religious Landscape Therapists across the US are becoming more and more familiar with clients like Lillian, who provides an example of the many ways that spiritual concerns can interface with therapy even among nonreligious clients. Part of this increasing familiarity is due to the shifting religious landscape in the US. The Pew Research Center (2015) has documented that from the years of 2007 to 2014, there has been a precipitous decline in both the total number and the percentage of people overall who identify with a religious tradition. The mainline Protestant and the Roman Catholic traditions have seen the greatest exodus of affiliates. Meanwhile, the number of nonreligious (those who identify as atheist, agnostic, and nothing in particular) has risen during that same time frame, the religiously unaffiliated or “nones.” This demographic also represents the largest minority of the millennial population. These now decade-old cultural winds prompted a focus on the cleaving of spirituality from religion, birthing what is now colloquially known as the “spiritual but not religious” phenomenon (Pew Research Center, 2012). Still, other fresh nuances continue to emerge today. Recent polling (Pew Research Center, 2018) finds that 39% of Americans are highly religious (Sunday Stalwarts, God-andCountry Believers, Diversely Devout), 29% are nonreligious (Religious Resisters and Solidly Secular), and 32% are those in between (Relaxed Religious and Spiritually Awake). The exponential growth in the latter two groups has prompted complex typologies to account for the varieties of atheism/agnosticism. For instance, Silver, Coleman, Hood, and Holcombe (2014) found six types of nonbelief in an American sample: intellectual atheist/agnostic (38%), activist atheist/agnostic (23%), seeker agnostic (8%), anti-theist (15%), nontheist (4%), and ritual atheist/agnostic (13%). Despite decreased belonging to religious organizations, however, religious traditions are often present in the developmental ecosystems of seemingly secular clients’ lives, for instance, through the faith and

Introduction 3 practices of friends or through family traditions. The reason for this is because even though the US culture is more secular than it has ever been, the majority of the population remains both religious and Christian. Christians represent about 70% of the population while minority traditions (including Jewish, Muslim, Buddhist, and Hindu, among others) make up about 6%. Likewise, despite the decline of Christian denominations, the number of people identifying with a minority tradition has increased by more than 1%. Thus, as was the case for Lillian, it is possible that spiritual and religious influences might lay dormant until life experiences unearth them again even if they do not identify with them at a given moment. For many in the industrialized West, spirituality and religion make an appearance through therapeutic or wellness practices, which they might pursue initially without any concern for the broader tradition from which that practice came. The broad appeal of meditation as a complementary and alternative medicine serves as a prime example; it often is seen in popular outlets ranging from Scientific American (Ricard, Lutz, & Davidson, 2014), to Shape (Editors of Shape.com, n.d.). However, these practices are powerful, and as studies of wellness-based and alternative spiritualities suggest (e.g., Bender, 2010; Heelas, 2008), for many who employ them, pathways develop from the practice into other spiritual and religious concerns, leading from wellness to exploring ethics or mysticism. For instance, individuals might enter a yoga class for exercise and become intrigued by its spiritual underpinnings. In the end, however, many individuals practice and believe without belonging (Davie, 1990), which can complicate notions of religious and spiritual identity. While many of the non-affiliated bring spiritual and religious concerns into counseling, it is also worth remembering that most individuals in the United States claim an explicit religious identity, and that religious adherence is even more the norm for individuals outside of the West where roughly 84% of the world’s population belongs to a religion (Pew Research Center, 2015). Interestingly, the projected numbers over the next 50 years predict an overall decline in the number of nonreligious globally (from 16% to 13%) even while these populations grow in Europe and the US. Thus, regardless of affiliation status, spirituality and religion are often important to clients from either background and are likely to remain that way for the foreseeable future.

Responding to What Clients Want This larger religious landscape has direct bearing on the practice of therapy. In a review of the literature on client preferences regarding religion and spirituality (R/S) in counseling, Harris, Randolph, and Gordon (2016) highlighted two consistent findings: most clients (a) want to be able to include R/S issues in therapy and (b) rate religiously supportive

4 Introduction therapists more highly. As client religiosity increased, the clinician’s knowledge and respect for R/S became increasingly important. For these clients, explicitly R/S interventions produce superior spiritual outcomes than do secular treatments while producing equivalent psychological benefits (Captari et al., 2018). In fact, even when a nonreligious strategy is adopted, clients will still credit their religion or spiritually as part of what helped them (Pargament & Rye, 1998; Pargament, 2011). For another group of clients, between 18–37% (Harris et al., 2016), religion and spirituality are salient in that they actively do not wish to discuss these issues and preferred therapists who focused on clinical skills. This polarized set of preferences creates a difficult path for therapists to navigate, since they must be open and supportive for clients who wish to include R/S but also able to avoid these topics for those who do not. The history of psychology exacerbates this problem. Pivotal figures such as Freud, Skinner, and Ellis belong among the “masters of suspicion” (Ricoeur, 2008) who tend to view R/S as a mask for darker motivations, such as infantilism, social control, or neurosis. While there are counterexamples such as Jung, therapy has tended to see only the downside of R/S. Therefore, until recently, therapists trained in mainstream programs have not received training in the positive use of R/S resources in psychotherapy and would not be likely to be able to give many clients what they desired. For this reason, many potential clients are suspect of just what kind of “help” they expect to receive from a therapist. Highly religious clients are more likely to seek out religious sources of help than they are to contact a therapist (Wamser, Vandenberg, & Hibberd, 2011). Likewise, religious clients sometimes worry that if they see a therapist, they will be judged for their beliefs and practices or will be asked to abandon them entirely (Mayers, Leavey, Vallianatou, & Barker, 2007). Since clinicians tend to be less religious than the general population (Shafranske & Cummings, 2013), differences in identity can complicate seeking help. Some religious groups have responded to this lack of clinicians whom they trust by developing their own approaches. Most notably, conservative Protestants have created a parallel source of therapists through the nouthetic or biblical counseling movement. Leaders of this movement, notably Jay Adams (1986), believed that psychology was promoting a picture of human nature that directly contradicted biblical teaching. Some of these biblical counselors eschew the notion of holding a therapy license while viewing counseling as the prerogative of the Christian church and the only sure means of believers receiving real or adequate help (Powlison, 2010). More hard-line versions also exist that denounce psychological science as “psychoheresy” (see www.psychoheresy-aware. org/mainpage.html). While some conservative Protestants have developed more accommodating approaches to traditional psychotherapy (Johnson, 2010), the de facto stance of many potential clients has been that only this parallel system is “safe” for people of faith. This situation

Introduction 5 limits access to treatment for many potential clients, not to mention that it provides no alternative for devout clients from traditions outside conservative Protestantism. Fortunately, mental health professionals have realized both the necessity and complexity of addressing R/S in therapy over the past two decades. In response, professional organizations have required R/S competence be an aspect of clinical training. For example, in 2009, The Council for Accreditation of Counseling and Related Educational Programs (CACREP) mandated that counselors be competent in addressing spirituality as a facet of multicultural competence and as a means of effective treatment of addiction. As this has become incorporated into counselor education, there has been a call to make R/S competence into a full-fledged curriculum area required of all counselors (Bohecker, Schellenberg, & Silvey, 2017). This change in accreditation followed a series of developments within the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) that proposed in 2009 a set of spiritual competencies for counselors to use when navigating spirituality and religion in therapy (see Robertson, 2008, 2010). Similarly, in 2013, The Society for the Psychology of Religion and Spirituality (APA Division 36) embraced R/S as a multicultural competency and more recently a set of spiritual competencies for psychologists was created (Vieten et al., 2013). Though not yet codified into a list of competencies as in counseling and psychology, recent scholarship in social work has also taken up the mission of developing competency-based measures in the field to promote more effective clinical practice (Oxhandler & Parrish, 2016).

The Discrepancy between Therapists’ Values and Practices Practitioners seem to agree that R/S competence is important. Surveys across professional disciplines (social work, psychology, marriage and family therapy, mental health counseling) have found that clinicians desire to have more discussion of R/S in their training (Oxhandler & Pargament, 2014). And yet, even among therapists who report that they feel competent with many aspects of integrating spirituality into therapy, studies have consistently found that they do not report using spiritual and religious resources in counseling to the extent that they rate these resources as important (Cashwell et al., 2013). For instance, most clinicians report never conducting a spiritual assessment with their clients (Oxhandler & Parrish, 2018). Since the assessment phase is the most pivotal time to raise topics that will be explored later, not directly assessing for R/S topics can send the implicit message that such areas are not welcomed in therapy. While therapists may endorse that R/S are potentially important areas to include in therapy, there is mixed evidence that they directly explore these areas. Some of this discrepancy may be related to therapists’ concern

6 Introduction to avoid harm in this central aspect of life, especially with limited training. For instance, in a sample of recent counselor trainees, the only area in which they did not feel prepared for practice was the cultural and social manifestations of clients’ spirituality and religion (Dobmeier & Reiner, 2012). For many clinicians, the level of competence required in current training standards does not appear to be adequate, and it is the rare program that has dedicated training on this area (Bohecker et al., 2017). A recent study of mental health counselors (Henriksen, Polonyi, Bornsheuer-Boswell, Greger, & Watts, 2015) found that more than 50% of participants indicated that their counselor education programs did not significantly address spirituality and religion. A survey of clinical social workers (Oxhandler & Giardina, 2017) also identified lack of training as a hindrance to R/S integration in therapy. Cashwell and Young (2004) conducted a content analysis of syllabi offering advanced graduate-level training in R/S topics, finding that that there is both wide variation in what constitutes “competence” and in how such topics are approached in practical scenarios. A common method that training programs have adopted to provide some exposure to R/S is to include it in a course covering multicultural issues. However, multicultural textbooks tend to lack a substantive engagement with the topic, so students tend to say they must seek additional training even when it is covered (Rupert, Moon, & Sandage, 2018). And beyond this lack of specific training, therapists report that there are programs and organizations in which R/S is still seen as a taboo topic (Oxhandler & Giardina, 2017). So, whether it comes in the form of passive neglect or more active rejection of the topic itself, standard training models for therapists across mental health disciplines tend to leave their students wanting. Under these current conditions, the way in which it appears that therapists are most comfortable bringing R/S into therapy is through nonsectarian, spiritual concepts already interwoven with counseling theory, such as hope and meaning or through practices such as the Serenity Prayer that are widely employed across treatments (Adams, 2012; Dobmeier & Reiner, 2012; Oxhandler & Pargament, 2014). These practices provide a workable baseline for improving competency, but they still fall short of the level of specificity that many clients hope to encounter. They certainly are not in line with the best-practice models proposed across mental health disciplines (Oxhandler & Parrish, 2016; Roberstson, 2008; Vieten et al., 2013). Further, clinicians’ preferences for engagement with such spiritual concepts can themselves reveal a certain bias. For example, while CACREP (2016) has included R/S terminology as essential topics of education, these standards are phrased in such a way that “spirituality” is used as a loose, generally positive concept without much specificity and “religion” is rarely mentioned. As Pargament (2011) argued, such bias can stem from viewing spirituality as the individual good guy and religion as the institutional bad guy, something that seems very easily left

Introduction 7 unchecked given that therapists tend to be less religious than the general population (Shafranske & Cummings, 2013; Young, Wiggins-Frame, & Cashwell, 2007). As we argue more fully herein, such sharp polarizations are unhelpful because clients often claim a religious tradition and see it as relevant to their psychological distress. Taken together, this pattern of findings suggests that an emphasis on R/S in therapy has increased awareness, but not translated into changes in practice. Mental health professionals want to know how to work with these issues in an ethical way but have not received training that is adequate to do so. It appears that Pargament’s (2011) postulation stills holds mostly true: “If my own experiences are any guide, many of our clients would welcome us into their spiritual homes if we knocked on the door. It seems the reluctance to visit is largely ours” (p. 16). This book is a response to this need. In it, we provide clinicians with a framework that can help them move from a position of appreciating R/S to using these constructs for the client’s good.

The Beautiful Mess of Contemporary Religion and Spirituality Part of the challenge is the lack of a model for integrating R/S into psychotherapy that embraces the complex, fluid, and negotiated nature of religion and spirituality. While there are many models that scholars have developed to connect R/S with psychotherapy, these models exhibit a wide disagreement as to what counts as meaningful and effective integration. As a result, approaches to R/S in therapy have tended to splinter into different clusters that rarely impact one another and have little to draw them together. A model that seems too theological or religious to some appears too spiritually vague and lacking in substance to others. For instance, many would agree that mindfulness practice is an example of clinically significant integration of R/S into psychotherapy. Metaanalyses across hundreds of studies have supported its efficacy to help alleviate a wide range of mental health–related problems (Sedlmeier et al., 2012). But when does mindfulness cross over from being a brain technology to psychospiritual integration? Is it integrative simply because it is drawn from Buddhism, which is often categorized as a World Religion? Is it integrative because it activates the ability of human consciousness to transcend ordinary reality? Is it integrative because it elicits spiritual emotions and a sense of the sacred? Is it integrative only if it is pursued as part of a way of life that leads to moral development? Is it in need of an analysis of its worldview before presenting it to clients of specific traditions? When does it cease being mindfulness proper and become a westernized mind technique intended for broad, almost panacea-like consumption, which some scholars have nicknamed “McMindfulness” (Neal, 2017)? Authors would rank these questions differently in terms of

8 Introduction their applicability and importance, and they would disagree on whether other models have adequately considered the matter. Compounding this lack of agreement is the fact that many of these models are developed in separate academic subdisciplines, each with its own canonical sources, ideas of sound scholarship, central concerns, and interlocutors. To name a few, there is clinical psychology (Pargament, 2011; Piedmont, 1999), existentialism (Frankl, 2014), psychiatry (Griffith, 2010), counseling (Cashwell & Young, 2014), addictions (Arnold, Avants, Margolin, & Marcotte, 2002), social work (Canda & Furman, 2009), couples and family therapy (Walsh, 2008), pastoral psychotherapy (van Deusen Hunsinger, 1995), Evangelical Christian counseling (Dueck & Reimer, 2009), transpersonal psychology (Wilbur, 2000), and Buddhist psychology (Kornfield, 2000). Each model has potential value, as we have seen in our experiences as clinicians and educators. With the richness of possible sources, there is a lot available for therapists to build their competence. However, the challenge is knowing how to navigate among them in a cohesive and practically useful way. Knowing where to begin can be daunting for even seasoned clinicians.

Fuzzy Concepts Clarity about R/S resists simple descriptions or consensus building, partly because of its complex structures and equally complicated associations with the rest of human psychology and social frameworks. Scholars have often seen the source of this lack of consensus lying in the “fuzziness” (Zinnbauer et al., 1997, p. 549) of the terms “religion” and “spirituality” themselves. In research, the most common strategy has been for authors to “unfuzzy” these constructs by defining religion and spirituality precisely, with spirituality often considered a universal human potential and religion as a social phenomenon. With this clarity, they can then define the content of R/S integration precisely and decide what is included and what is not. Clarity is essential for designing empirical research, especially for the purposes of assessment and measurement. Researchers need to be able to compare their results and offer specific conclusions based on the exact phenomena they are studying. For instance, one common goal of researchers into the psychology of R/S is to establish spirituality and religion as distinct and sui generis (irreducible to other constructs). This goal is often pursued through a strategy of incremental validity (Piedmont, 1999), which demonstrates that a research construct such as spirituality is sufficiently different from other established ones in its ability to predict outcomes; that it is worth keeping as a separate variable and is not just the “religification” (Van Wicklin, 1990) of variables such as personality or goal direction. This strategy has established the psychology of R/S as a legitimate domain of study, and along the way, these precise definitions have been further parsed into a

Introduction 9 variety of mid-level constructs that pertain to clinical practice, such as God-image (Lawrence, 1997); R/S coping (Pargament, Koenig, & Perez, 2000); mysticism (Hood, Morris, & Watson, 1993); spiritual struggles (Exline, Pargament, Grubbs, & Yali, 2014); spiritual bypass (Fox, Cashwell, & Picciotto, 2017); and practices such as forgiveness (McCullough et al.,1998), gratitude (McCullough, Emmons, & Tsang, 2002), and mindfulness (Brown & Ryan, 2003). This research has had immense benefit, and we explore its strengths and weaknesses in Chapter 8. The problem is that clients do not make these fine distinctions, and they often utilize language of R/S in multiple, overlapping ways, as seen in the most recent sociological research on the topic. For instance, the sociologist Nancy Ammerman (2013) interviewed and collected archival information from participants living in the diverse R/S milieus of Atlanta and Boston. After asking participants to describe what is spiritual to them using a variety of methods, Ammerman (2013) concluded that “all our participants—affiliates and non-affiliates, active and inactive alike— employed multiple definitional tacks over the course of their contributions in the interview, diaries, and descriptions of their photos. Indeed, the clear majority of their references to spirituality moved across multiple categories—Awe and God, Ritual and Mystery, Meaning and Morality— often even within the same story” (p. 265). Not every therapist or client will see something as spiritual or religious in the same way; in fact, they may even evoke multiple understandings of these terms within their interactions that do not simply agree or disagree with one another. Moreover, “religion” and “spirituality” are terms under negotiation in contemporary Western society (Ammerman, 2013), not to mention in the academic disciplines. They are not sitting still to allow us to measure them, even if we must define them precisely for quantitative research. While consensus among empiricists is one issue, consensus with the broader public whom therapists serve is a whole other problem entirely. Clinicians can’t simply remove the fuzziness of language from their work; clients will bring that with them. Perhaps a better starting point for clinical practice is to come at R/S not out of a desire for neatness, but out of a desire for thickness: giving a picture of the web of relationships present between R/S and the everyday experiences of clients. In looking at R/S through the lens of their lived realities in clients’ lives (what scholars have called “lived religion”; see Hall, 1997), we are poised to appreciate the fluidity and variety of contemporary R/S.

The Lived Reality of Contemporary Religion and Spirituality The approach of “lived religion” developed in religious studies from criticisms that scholarship had focused too much on the officially sanctioned

10 Introduction aspects of R/S, which tell us very little about the experiences of ordinary people as opposed to religious professionals and elites. Rather than focusing on “creed, code, and cult,” lived religion is organized around “domains of life where sacred things are being produced, encountered, and shared” (Ammerman, 2016, p. 10). For many, these practices take place inside religious organizations; the focus on lived religion recognizes that there is a rich interplay between individuals and their social influences and chooses to focus on what people are actually doing (Ammerman, 2016) as they negotiate between their own experiences and the norms and practices of groups they belong to. We believe focusing on lived religion as Ammerman (2016) suggested is helpful for the following reasons: First, this focus on practice and improvisation is especially pertinent given the trend of fluidity in cultures influenced by global capitalism. In “liquid modernity,” relationships are valued for their revocability and tend to flow together and apart (Bauman, 2013). In this milieu, R/S is also structured as fluid, a do-it-yourself quest which utilizes traditions in an open-source way, borrowing and piecing aspects of them together without granting deference to ideas simply because they have official sanction (Stewart-Sicking, 2016). This fluidity can be a mixed blessing since it gives freedom without giving guidance. And understanding these dynamics is important for therapists who wish to address R/S in psychotherapy, since it creates a messiness that is simultaneously fascinating and difficult to grasp. Second, this approach has high ecological validity. Unless therapists broadcast clearly that they are specialists in the area of R/S in some easily discernible and narrow manner (e.g., pastoral counselor, Christian counselor), they are likely to encounter a wide spectrum of clientele who usually seek out therapists for reasons unrelated to R/S, but this wide net will inevitably attract a diverse set of clients from all parts of the R/S spectrum. Third, a thick approach to R/S resists the temptation toward false dichotomies and extreme polarization which Zinnbauer and Pargament (2005) have cautioned against. As surveys of the general population have found, most people do not identify as one or the other; rather, most would say they are spiritual and religious (Marler & Hadaway, 2002; Pew Research Center, 2015). Last, this approach allows clinicians flexibility to meet clients where they are at in therapy, providing a starting place for conceptualization while not predetermining the source or the destination of clients’ R/S realities. This flexibility allows a diverse set of responses for approaching clients’ core concerns. The starting place for this lived religion approach is to view R/S as composed of several packages of meaning. R/S Comes in Packages In addition to finding that spirituality can be construed across multiple definitions, and these can be endorsed by the same person

Introduction 11 simultaneously, Ammerman also found that there are at least four common configurations in the contemporary, English-speaking West of what can be called “religion” and “spirituality”: theistic, extratheistic, ethical, and religious (Ammerman, 2013, 2014). Theistic packages focus on the presence of a mysterious, but personal God that is active in the world, including the practices that deepen that relationship. Extra-theistic packages configure around experiences of transcendence—through the transpersonal self, community, aesthetics, the natural world, or a guiding life philosophy—that are greater than the autonomous self and beyond the ordinary. Ethical spiritualities focus on living a virtuous life and seeking the good beyond one’s own interests. Last, religious packages of spiritual discourse, also known as “belief and belonging spirituality,” emphasize belief in doctrine about God and belonging to religious traditions. Importantly, these four packages are not incommensurable. Moreover, different contexts may elicit different configurations of spiritual and religious discourse—even within the same person (Bender, 2007). Therefore, in this book, we intend to capitalize on this manifest ambiguity to provide a comprehensive consideration of how religion and spirituality may be construed within therapy.

A Different Approach For this book, we consider R/S to be present in therapy whenever there is a connection to that which is “sacred, transcendent, or beyond the ordinary” (Ammerman, 2007, p. 225). How religion and spirituality are construed within these types of experiences depends on the cultural realities of the therapist and client. Likewise, we define the integration of R/S into therapy as the act in which a therapist’s practical reason—how the therapist decides what to do—draws on both psychological and R/S sources. For instance, a therapist working with a Pentecostal Christian client struggling with the aftermath of childhood sexual abuse may look both to understandings of trauma and attachment as well as the ways in which Pentecostal spirituality understands God’s healing power as profound and bodily. There are many ways to understand the relationship between these two types of sources (e.g., dialogue, translation, critique, complementarity; cf. Doering, 2009), all of which should be considered the integration of religion or spirituality into therapy, or as the title of this book suggests, bringing religion and spirituality into therapy. This process of how religion and spirituality is brought into therapy is dynamic and can originate from either the therapist’s or the client’s initiative. Taking a thick approach rather than a universal one also allows us to avoid some of the strongest critiques made against research into the psychology of R/S: namely, that it ignores the historical and particular nature

12 Introduction of these concepts as they developed out of a specific history influenced by the Protestant Christian intellectual concerns that underlie Western academia (Asad, 2003). For instance, defining R/S through reference to the “sacred” (Pargament, 2013) as opposed to the secular, tends to privatize its importance and reduce its political features (Asad, 2003). Similarly, a focus on interwoven belief and practice corrects for the tendency to make symbolism (Geertz, 1975), meaning (Park & Paloutzian, 2005), or cosmology (Orton & O’Grady, 2016) the central focus of study. Universal categories for R/S have helped research mature, but at the same time, they have tended to push out the experience of people at the margins of the dominant groups. For instance, much of the psychological research on R/S assumes a belief in God (theism) and has been conducted on Westerners who are grounded in a single tradition. This research is difficult to generalize to many of the populations that are growing most quickly in Western society: people with hybrid identities, non-theists, non-adherents, polytheists and neo-pagans, and non-Westerners. We want to include these groups from the outset. A thick approach to R/S also highlights the ways therapy is inextricably interwoven with these domains. As Browning and Cooper (2004) wrote, “Traditional religion and modern psychology stand in a special relation to one another because both provide concepts and technologies for the ordering of the interior life” (p. 2). One simply cannot apply the science of psychology to therapy without recourse to concepts that can be construed as spiritual or religious. Schools of therapy make assertions about human nature, the purpose of life, the nature of the human condition, suffering, the meaning of being present to another, the good society, and the good of caring for others. All these concepts are near the core of many R/S worldviews. Conversely, R/S cannot exist without recourse to a science of mind, relationships, behaviors, and emotions. For example, they necessarily involve accounts of spiritual experience, human transformation, habit formation, selfhood, and healthy development that directly depend on psychology. Psychospiritual integration is inherent in therapy. True Pluralism Consistent with a thick approach we take in this book, our perspective is based upon pluralism. True pluralism, however, is not merely diversity, tolerance, and relativism, but encounter and dialogue (Eck, 2007). A pluralistic approach recognizes real and irreducible differences as well as common ground between therapist and client value commitments. As such, several guiding principles define the quality of encounter that pluralistic practice aspires to. First, pluralistic practice is self-consciously and self-critically aware of value commitments. Awareness of one’s value commitments is vital to intervening in the fabric of human life. Otherwise, clinicians are

Introduction 13 susceptible to unconsciously projecting their own worldviews onto clients. This is contrary to what may be common misconceptions of pluralism as philosophical relativism, where value commitments are treated as private commitments with little if any generalizable meaning outside one’s personal perspective. Pluralism not only recognizes the distinctiveness of personal value commitments but also sees them as integral to the discussion. As Eck (2018) has said, “Pluralism does not require relinquishing the distinctiveness of one’s own tradition of faith to reach the ‘lowest common denominator.’ In the public square of a pluralist society, commitments are not left at the door, but invited in.” Second, pluralistic practice can trace those value commitments to formative sociocultural and historical contexts. No one grows up value neutral. Rather who we are and the values we hold are all formed deeply by our context. In other words, it matters deeply if we grew up religious or not religious, if our family taught us how to trust in clergy for the answers or to view religious leaders with suspicion, whether our education was faith based or embraced the enlightenment ideals of separation of church and state, if we were taught that every living being is a spark of the divine or if we draw distinctions between human and animal species, if outsiders are to be feared or if hospitality, even to enemies, is morally upright, etc. The list could go on for pages. While not every statement about the world is reducible down to a solipsism, where our perspective of the world is just self-referential, pluralistic practice takes seriously these formative contexts and messages we come to adopt over a lifetime. Last, pluralistic practice engages with and commits to understanding difference and common ground in value commitments in a curious, open, and empathic way. Sadly, there are widespread misconceptions for many regarding how to approach differences as they surface in R/S topics. For many there seem to be only two options. The first option is to approach differences through outright defensiveness or violence, physical and/or verbal. This is the response we witness in the worst of religious fundamentalism or its identical twin in the form of militant secularism: one that seeks the violent conquest of competing foes and contrary ideologies. Differences are viewed as a zero-sum game, where there is always a winner and a loser. The second option is a passive tolerance of differences. While this may be preferable for many when compared with violent conquests, the net result is still a lack of significant engagement. When tolerance abounds, dialogue is quickly extinguished. While violence moves to an extreme of a “hands on” approach in the form of a will to power, passive tolerance moves toward the other extreme of a “hands off” indifference. Not in every instance, but tolerance can sometimes be fueled by an internalized sense of moral superiority, a feeling of “I can tolerate you; why can’t you tolerate me?” Neither position is a suitable starting place for true dialogue, especially around topics so far reaching

14 Introduction and significant as R/S are for many people. By contrast, the words of Pope Francis are a helpful guide: Dialogue is born from a respectful attitude toward the other person, from a conviction that the other person has something good to say. It assumes that we can make room in the heart for their point of view, their opinion, and their proposal. Dialogue entails a warm reception, not a preemptive condemnation. To dialogue, one must know how to lower the defenses, to open the doors of one’s home, and to offer warmth. (Bergoglio & Skorka, 2013, pp. XIII–XIV) Pluralism as a commitment to dialogue is more challenging than violence or tolerance because it requires both vulnerability and openness to newness of perspective born of a sincere humility that fully embraces one’s uniqueness and limitations while simultaneously embracing the Other, not as enemy, but as a companion in the quest for truth. The Need for Professional Pluralism Pluralism is needed to function effectively as a helper, without respect to any specific training background. Thus, we believe that a pluralistic model is also needed to speak to multiple professions, all of whom encounter R/S in their work with clients. To that end, we have intentionally chosen to use the words “therapy” or “therapist” in this book. We specifically wrote this book with those professions in mind most often tasked with talk therapy, including counseling (including various related disciplines such as pastoral counseling), psychology, and social work. It is therefore our sincere desire to continue a stream of increasing dialogue across professional identities and theoretical models to best serve those who need it most: the thousands of vulnerable individuals who seek out our help in therapy sessions and who often carry with them both the sources of healing and, potentially, the burdens of complicated R/S histories that emanate from their experiences, beliefs, and practices. Process: The “How” of Practice The focus of our model, surely based upon a pluralistic framework, is on how R/S is brought into therapy. The approach we take is not linear, proposing one starting place followed by stepwise sequences of what to do next. Rather, we see R/S as far more dynamic than what a linear model can handle when translated into practice; real-world environments are highly organic and evolve and change over time.

Introduction 15 To help therapists effectively understand the ways in which R/S can be brought into their work, we use a tool we have found helpful in our own teaching and practice, the Ways Paradigm, which was originally developed by our esteemed colleague Sharon Cheston in 2000 to teach counseling theory. The paradigm consists of three dimensions—a way of understanding, a way of being, and a way of intervening. Cheston (2000) contended that “every major theory addresses the above three ways in proposing how a theory is helpful to counselors in working with clients” (p. 256). We extend this premise to say that not only does every major theory of therapy possess these dimensions, but also every R/S tradition does as well. The Ways Paradigm indeed focuses on the “what” of R/S alongside psychological science, but it also encapsulates the what in the “how” these two major dimensions of human thought, inquiry, and living encounter each other. In other words, the Ways Paradigm, as we have adapted it, focuses on the process of R/S integration. We believe that a process model, like the Ways Paradigm, is thick enough to funnel each psychological and R/S perspective into a framework that makes cross comparison much more flexible, easy to remember, and therefore, practical in application. First, a way of understanding involves “the body of counseling knowledge that explains personality theory and structure, normal and abnormal human development, and different ways people change” (Cheston, 2000, p. 256). While often only implicit in the therapy session, this knowledge provides the basis for approaching treatment. Therapists may not share their case conceptualizations with clients, but ways of understanding are conscious strategies for understanding what is happening in the client’s life and how to help. In terms of sheer volume, this is the area that both theorists of western therapy and R/S writers have spent most scholarly energy. Thus, it often requires the most time to consume and become conversant with. Ways of being include “who the counselor is, the degree of empathy expressed, the values the counselor demonstrates, the boundaries that are set, [and] the importance’s ascribed the relationship” which establish “an atmosphere in which change can occur” (Cheston, 2000, p. 256). Ways of being are fundamental to the progress of counseling, but they often remain tacit, unarticulated by both the therapist and the client. Ways of being are habitual modes of attention and presence with the client, and even when not named, they remain central to the success of therapy. Therapists’ ways of being have been a focal point ever since Freud required that analysts underwent analysis to understand how transference and countertransference dynamics influence their presence with clients. Carl Rogers’ conditions of congruence, empathy, and unconditional positive regard—now widely accepted across theoretical modalities—was a paradigm shift for therapeutic ways of being. R/S traditions too have

16 Introduction recognized the power of formational processes through which a person is shaped with a new set of dispositions. Finally, ways of intervening are defined as “the work of therapy . . . the means by which a counselor interrupts the client’s cycle of dysfunction and allows for the processing of healthier alternatives of thinking, feeling, and behaving” (Cheston, 2000, p. 257). There are, of course, hundreds of interventions to choose from drawing from diverse strands of therapeutic schools of thought. Regardless of their theoretical or practical origins, interventions are where religion and spirituality are addressed in therapy, and they can move from the clinician’s office into the client’s daily life. Ways of intervening are where the action of therapy takes place, and R/S integration is both implicitly and explicitly negotiated between therapist and client. Much like ways of understanding, this is an area that has attracted much scholarship. Rather than provide an appendix of common practices, we instead provide a framework for understanding where R/S interventions originate from, how they may be adapted to therapy, and the intended goals they espouse for creating change. As with many descriptions of psychotherapy, the dimensions of the Ways Paradigm are not intended to have hard boundaries, but instead are a way of conceptualizing a complex and fluid reality. Nonetheless, these three dimensions—understanding, being, and intervening—parallel many other descriptions of practice. For instance, Friedrich Schleiermacher (2016), a seminal figure in Western theology and religious studies, speaks of knowing (understanding), feeling (being), and doing (intervening) as the three dimensions of human action. This threefold division is also seen in Western philosophers from Plato to Kant in the transcendental categories of the true (understanding), the beautiful (being), and the good (intervening). This makes the ways paradigm especially applicable for modern educational contexts where these three areas (i.e., knowledge/ understanding, attitudes/dispositions, and skills/interventions) are widely used to assess competence in applied fields. Most importantly, The Ways Paradigm has many characteristics that make it well-suited for exploring how R/S might be integrated into counseling. It is, by design, independent of any stream of therapeutic theory while also being able to accommodate the breadth of theories counselors use. This is especially apropos for the current climate of therapy since most clinicians are integrative or eclectic in practice (Prochaska & Norcross, 2018). Likewise, it does not specify how the practitioner relates psychology to religion and spirituality, thus resisting any a priori clinician qualifications from the standpoint of identity (religious, spiritual but not religious, or neither). The approach we are advocating for can be practiced with or without an affiliation to a religious tradition. It also reflects the growing interest in therapists’ dispositions alongside their knowledge and skills. Finally, its three dimensions provide a straightforward and nonreductive way to conceptualize approaches to counseling.

Introduction 17 This broad framework allows us to tie together many strands of scholarship into R/S in counseling that cross disciplines such as psychology of religion/spirituality, pastoral counseling, transpersonal psychology, depth psychology, and existential/humanist counseling rather than getting stuck in disputes within each field. In doing so, it provides a map for the broad landscape of existing models integrating R/S into counseling. It also provides insight and questions that tend to be ignored when looking at integration only from within a single model, including the diverse manifestations of R/S in contemporary society. Our goal is that readers emerge from this book better oriented to the ways R/S can be brought into their work as therapists and therefore ready to approach in a critical manner the many ways in which integration has been described in the literature and can be adapted to their practice. In doing so, therapists will be able to deepen their knowledge, dispositions, and skills in R/S dimensions of therapy.

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20 Introduction Oxhandler, H. K., & Giardina, T. D. (2017). Social workers’ perceived barriers to and sources of support for integrating clients’ religion and spirituality in practice. Social Work, 62(4), 323–332. https://doi.org/10.1093/sw/swx036 Oxhandler, H. K., & Pargament, K. I. (2014). Social work practitioners’ integration of clients’ religion and spirituality in practice: A literature review. Social Work, 59(3), 271–279. https://doi.org/10.1093/sw/swu018 Oxhandler, H. K., & Parrish, D. E. (2018). Integrating clients’ religion/spirituality in clinical practice: A comparison among social workers, psychologists, counselors, marriage and family therapists, and nurses. Journal of Clinical Psychology, 74(4), 680–694. Pargament, K. I. (2011). Spiritually integrated psychotherapy: Understanding and addressing the sacred. New York, NY: Guilford Press. Pargament, K. I. (Ed.). (2013). Searching for the sacred: Toward a nonreductionistic theory of spirituality. In APA handbook of psychology, religion, and spirituality (Vol 1): Context, theory, and research (pp. 257–273). Washington, DC: American Psychological Association. Pargament, K. I., Koenig, H. G., & Perez, L. M. (2000). The many methods of religious coping: Development and initial validation of the RCOPE. Journal of Clinical Psychology, 56(4), 519–543. Pargament, K. I., & Rye, M. S. (1998). Forgiveness as a method of religious coping. Dimensions of Forgiveness: Psychological Research and Theological Perspectives, 59–78. Park, C. L., & Paloutzian, R. F. (2005). Religion and meaning. In C. L., Park & R. F. Paloutzian (Eds.), Handbook of the Psychology of Religion and Spirituality, 2, 357–379, New York: Guilford. Pew Research Center. (2012, October 9). “Nones” on the rise. Retrieved from https://www.pewforum.org/2012/10/09/nones-on-the-rise/ Pew Research Center. (2015). Religious landscape study. Retrieved from www. pewforum.org/religious-landscape-study/ Pew Research Center. (2018, August 29). The religious typology: A new way to categorize Americans by religion. Retrieved from https://www.pewforum. org/2018/08/29/the-religious-typology/ Piedmont, R. L. (1999). Does spirituality represent the sixth factor of personality? Spiritual transcendence and the five-factor model. Journal of Personality, 67(6), 985–1013. Powlison, D. (2010). A biblical counseling view. In E. Johnson & D. Myers, (Eds.), Psychology & Christianity: Five views (2nd ed.) (pp. 246–273). Downer Grove, IL: Intervarsity Press. Prochaska, J. O., & Norcross, J. C. (2018). Systems of psychotherapy: A transtheoretical analysis. New York, NY: Oxford University Press. Ricard, M., Lutz, A., & Davidson, R. J. (2014, November). Neuroscience reveals the secrets of meditation’s benefits. Scientific American. Retrieved from https://www.scientificamerican.com/article/neuroscience-reveals-the-secretsof-meditation-s-benefits/ Ricoeur, P. (2008). Freud and philosophy: An essay on interpretation. Delhi, India: Motilal Banarsidass Publisher. Robertson, L. A. (2008). The spiritual competency scale: A comparison to the ASERVIC spiritual competencies. Orlando, FL: University of Central Florida. Retrieved from https://login.ezproxy.net.ucf.edu/login?auth=shibb&url=https://

Introduction 21 search.ebscohost.com/login.aspx?direct=true&db=cat00846a&AN=ucfl.0294 20212&site=eds-live&scope=site Robertson, L. A. (2010). The spiritual competency scale. Counseling and Values, 55(1), 6–24. Rupert, D., Moon, S. H., & Sandage, S. J. (2018). Clinical training groups for spirituality and religion in psychotherapy. Journal of Spirituality in Mental Health, 1–15. Schleiermacher, F. (2016). Christian faith (Two-Volume Set): A new translation and critical edition. Louisville, KY: Westminster John Knox Press. Sedlmeier, P., Eberth, J., Schwarz, M., Zimmermann, D., Haarig, F., Jaeger, S., & Kunze, S. (2012). The psychological effects of meditation: A metaanalysis. Psychological Bulletin, 138(6), 1139. Shafranske, E. P., & Cummings, J. P. (2013). Religious and spiritual beliefs, affiliations, and practices of psychologists. In APA handbook of psychology, religion, and spirituality (Vol 2): An applied psychology of religion and spirituality (pp. 23–41). https://doi.org/10.1037/14046-002 Silver, C. F., Coleman, T. J., Hood, R. W., & Holcombe, J. M. (2014). The six types of nonbelief: A qualitative and quantitative study of type and narrative. Mental Health, Religion & Culture, 17(10), 990–1001. doi:10.1080/136746 76.2014.987743 Stewart-Sicking, J. A. (2016). Spiritual friendship after religion. New York, NY: Morehouse. van Deusen Hunsinger, D. (1995). Theology and pastoral counseling: A new interdisciplinary approach. William B. Eerdmans Publishing Company. Van Wicklin, J. F. (1990). Conceiving and measuring ways of being religious. Journal of Psychology and Christianity, 9(2), 27–40. Vieten, C., Scammell, S., Pilato, R., Ammondson, I., Pargament, K. I., & Lukoff, D. (2013). Spiritual and religious competencies for psychologists. Psychology of Religion and Spirituality, 5(3), 129–144. https://doi.org/10.1037/a0032699 Walsh, F. (2008). Spiritual resources in family therapy. New York, NY: Guilford Press. Wamser, R., Vandenberg, B., & Hibberd, R. (2011). Religious fundamentalism, religious coping, and preference for psychological and religious treatment. International Journal for the Psychology of Religion, 21(3), 228–236. Wilber, K. (2000). Integral psychology: Consciousness, spirit, psychology, therapy. Boston, MA: Shambhala Publications. Young, J. S., Wiggins-Frame, M., & Cashwell, C. S. (2007). Spirituality and counselor competence: A national survey of American counseling association members. Journal of Counseling & Development, 85(1), 47–52. Zinnbauer, B. J., & Pargament, K. I. (2005). Religiousness and spirituality. In R. F. Paloutzian & C. L. Park (Eds.), Handbook of the psychology of religion and spirituality (pp. 21–42). New York, NY: Guilford Press. Zinnbauer, B., Pargament, K., Cole, B., Rye, M., Butter, E., Belavich, T., & Kadar, J. (1997). Religion and spirituality: Unfuzzying the fuzzy. Journal for the Scientific Study of Religion, 36(4), 549–564.

2 Ways of Understanding

Wisdom traditions often allude to the double edge of knowledge. In the words attributed to Solomon, “With much wisdom comes much sorrow; the more knowledge, the more grief” (Ecclesiastes 1:18 NIV). Knowledge obscures and blinds as much as it reveals. For all these cautions about the limits of knowledge, the capacity to understand is central to what make us human—Homo sapiens—the beings for whom knowing matters Therefore, the challenge of understanding human lives is something that is both essential to clinical practice and freighted with R/S implications.

Defining Ways of Understanding According to Cheston (2000), a way of understanding “involves the body of counseling knowledge that explains personality theory and structure, normal and abnormal human development, and different ways people change” (p. 256). It is worth noting that concepts such as human nature and development have unavoidable R/S components. Counseling deals with ultimate concerns and questions of self-transcendence, just as religion and spirituality provide concrete guidance about how to live a healthy and meaningful life. Therefore, counseling theory and R/S represent distinct, but overlapping, narratives about those most essential questions about what it means to be human. By viewing counseling and R/S as traditions that have implications for understanding human experience, we can integrate the healing insights of both into the counseling process and approach these themes from either starting point. Seeing ways of understanding as coherent traditions of speaking about human experience, we can view a client’s situation from multiple approaches, empowering a pluralistic approach to integrating R/S in therapy. In taking this perspective, we are presuming that there are some areas in which psychology and R/S come into conversation with each other. Each perspective draws from distinctive philosophical roots in helping us understand questions concerning human suffering and flourishing, and how therapy helps clients move from the former to the latter. Whether integration is practiced in an explicit way in a religious context

Ways of Understanding 23 or implicitly in a nonreligious context, the rationale for integrating ways of understanding is the same—expanding therapists’ perspective and ability to attend to themes that have R/S resonance.

Creating a Space for Building Bridges Therapy and religion have had collaborative (James, 1902/1936; Jung, 1950) and adversarial (Ellis, 1980; Freud, 1961) relationships, but rarely indifferent ones. In the classical traditions of both West and East, psychological wisdom was embedded in religious and philosophical traditions, such as Stoicism, Buddhism, or Christianity (Hadot, 1995). Science and theology often partnered in examining everything from human behavior to the nature of the cosmos. However, in the eighteenth century, a different picture began to emerge in Western thought, one in which science slowly, but decidedly, saw itself as an alternative to these classical traditions. To understand how R/S integration has come to look the way it does in the helping professions, we need to briefly pause for a philosophical and historical rest stop.

Historical Context on Integrating Religion and Science Historians call this trend “the Enlightenment,” and it is told as the story of our courageous “coming of age” having overcome dark and superstitious ways of thinking through commitment to the light of reason (Taylor, 2007). A highly condensed version of the tale sees enlightenment as disenchantment (Weber, 1977): Once, the universe seemed to be permeated with all sorts of supernatural energy and beings. Over time, science showed that this picture was unnecessary and hindered true knowledge and human freedom. As a result, Western thought became disenchanted, believing that it had matured from needing to rely on supernatural explanations for events. Instead, it embraced naturalistic reductionism: that natural events should be explained only through other natural causes. Therefore, in Nietzsche’s infamous pronouncement, “God is dead. God remains dead. And we have killed Him” (Nietzsche as cited in Kaufmann, 1974, p. 97). This secular, disenchanted self-understanding has dominated psychology throughout much of its modern history and is in part responsible for the disappearance of R/S ways of understanding in helping relationships and their replacement with naturalistic, medical ones. If this story were true, there would be no need for this book. While some scholars argue that secular reason has all but eclipsed religion in the West (Bruce, 2002, 2006), the reality seems more nuanced. First, not everyone in Western societies sees the world through the lens of modern Western philosophy. There are different ethnic, spiritual, and religious groups that see transcendence as a key part of their worldview. As we

24  Ways of Understanding discussed in Chapter 1, the ways in which R/S enters into contemporary Western culture include both theistic and extratheistic packages (Ammerman, 2013. Surveys suggest that belief patterns are becoming less traditional, but that belief in things that fall outside the realm of ordinary experience is widespread, whether that takes the shape of traditionally religious beliefs (such as a belief in a God) or alternative spiritualities such as a belief in a “life force” or paranormal events or transcendence in encountering nature (Pew Research Center, 2015). How then can therapists engage R/S ways of understanding that are rapidly becoming more diverse and link them to counseling theory?

Psychospiritual Themes as a Bridge Concept An extensive literature exists on the integration of psychotherapy and R/S. There are Buddhist psychotherapies (Brazier, 1995; Epstein, 1995; Kornfield, 2009), Christian psychotherapies (Browning, 2004, 2010; CooperWhite, 2011; Dueck & Lee, 2005; Dueck & Reimer, 2009; Farley, 2005; Grieder, van Deusen Hunsinger, & Kelcourse, 2010; Ulanov & Dueck, 2008; van Deusen Hunsinger, 1995), spiritually oriented psychotherapies (Sperry & Shafranske, 2005), pastoral psychotherapies (Doehring, 2006; Maynard & Snodgrass, 2015; Townsend, 2009), spiritually integrated psychotherapies (Pargament, 2007), spiritually informed therapies (Cashwell & Young, 2011; Frame, 2003; Robert & Kelly; 2015), spiritual but not religious and depth psychology approaches (Elkins, 1998; Hillman, 1991; Johnson, 2013; Moore, 1992, psychology of religion approaches (Dowd & Neilsen, 2006; James,1902/1936; Jung, 1950; Park & Paloutzian, 2005), and religious diversity approaches (Richards & Bergin, 2000). The literature is vast and growing, with varied philosophical assumptions, religions, denominations, and therapeutic theories throughout. With so many possible combinations, it is easy to get lost. Instead of covering each model in a linear fashion, we have found it useful in both educating therapists and in our own practice to use the concept of psychospiritual themes to open up these models. A psychospiritual theme is a bridge between psychological and R/S ways of understanding that can be applied to therapy. Psychospiritual themes straddle and connect the world of psychological life and our sense of the spiritual that is greater, beyond, and transcends the self. These themes can be seen in both historical soul care traditions and the modern psychotherapies. Like Jung’s (1980) archetypes, they are open to a multiplicity of contents, depending on the worldview and traditions embodied in the clinical relationship. As such, psychospiritual themes can accommodate diverse traditions in a pluralistic setting. The themes we discuss herein are neither an exhaustive list, nor a fully comprehensive overview of ways to conceptualize their psychological or R/S meanings. However, the four themes of self, suffering, change,

Ways of Understanding 25 and flourishing, when taken together, represent the narrative arc implicit in the course of therapy—Who is this person? Why are they suffering? What changes are they wanting to make? and What is the vision of hope and flourishing directing the work? Focusing on these four psychospiritual themes will provide a picture of how they can be integrated across the course of therapy. We make no claims to offer a “view from nowhere,” that is, a set of themes that are totally independent of any tradition or perspective. The way we have selected and described these themes inevitably reflects our particular standpoints and blind spots. In the interest of demonstrating the breadth of what clinicians could encounter in linking clients’ psychological and spiritual ways of understanding, we have cast the net wide. However, in doing this, we are unable to do much more than demonstrate that such links are there to be made, drawing attention to different traditions without being able to give much nuance to how the themes play out in them. We encourage readers to bring their own interpretive positions in thinking through these and other possible themes, and to deepen their knowledge of those traditions they regularly encounter. The aim in reviewing psychospiritual themes is to provide a scaffolding for engaging the many potential R/S meanings clients bring to therapy, which can include anything in lived experience that is “sacred, transcendent, or beyond the ordinary” (Ammerman, 2013). We are presuming that psychospiritual themes are bridges—places in which reflection coming from psychological and R/S perspectives connect to each other. In presuming that there are indeed such bridges, we are following the majority of scholarship on integration that takes dialogue as its model. However, it is worth noting the other possibilities (see, e.g., Barbour, 2000): that R/S and psychology both explain the same thing and therefore only one is really needed (reduction) or that R/S and psychology describe completely distinct components of reality and therefore no link is possible (incommensurability). Again, if either of these were true, a book of this type would not be necessary. Taking the bridge as the image of dialogue allows us to explore psychospiritual themes in a consistent way, describing the point of contact and the paths out of both R/S thought and psychology that lead to this interchange. In one way, a bridge is too simplistic an image in that the intersection isn’t some simple point, but rather a deep mystery. Psychospiritual themes plumb the depths of the human condition, and neither psychological nor R/S language can completely exhaust their meaning. Since psychospiritual themes have depth, describing them involves both positive assertions and negative deconstructions of what we have said. R/S traditions have a history of utilizing ways of saying and ways of unsaying (Sells, 2011), sometimes described as dialectic, to approach such topics. The same is not true of psychological theory, at least in most schools, since the goal is to come to parsimonious explanations. For this

26  Ways of Understanding reason, one of the benefits of integrating R/S language into clinical work is to preserve an attitude of reverence in the face of the mystery of human experience that is often lacking in psychological approaches outside of traditions such as existentialism.

Self The psychospiritual theme of the self pertains to questions of identity, understanding, human nature, and relationships. Therapy requires some understanding of what people are constituted from and what people are for. Our understanding of how the self relates to what is sacred, transcendent, and beyond the ordinary (Ammerman, 2013)—the territory of philosophical and theological anthropology—guides the ways in which we care for ourselves and others (Foucault, 1980). Therefore, even reductionistic approaches that see people in purely functional terms, as if therapists were neural mechanics getting a machine running smoothly, have some philosophical underpinnings that resonate with R/S ways of understanding. They simply assume that the self is unrelated to what is beyond the ordinary. R/S traditions provide a rich set of images, practices, and goals (Macintyre, 1981) for exploring selfhood. As these traditions have lost their influence, we have become free to construct a wide range of selves but get very little authoritative direction as we do so (Bauman, 1998). To connect R/S and psychological understandings of the self, we explore three common themes addressed by both perspectives. Though others exist, these three interrelated qualities—desire, relationship, and wise-transcendence—epitomize lived experiences of the self in relation to the sacred. The Desiring Self The self is necessarily connected to desire. For instance, Kornfield (2009) identified desire as the driver of life: “Without continuing desire we would die . . . when people lose their desire to live they jump off a bridge or swallow pills. We need desire” (Kornfield, 2009, p. 185). Desire is the primordial hunger that reaches for, grasps, and feels around for the world. It creates through dissatisfaction and restlessness, psychological states, but it is also spiritual. Understanding the Desiring Self through Psychology Desire is a key psychological category. For instance, Freud’s (1949) entire theory of personality and pathology is based upon reconciling the desirebased pleasure principle with the reality principle of what is available and socially sanctioned. Existential approaches look to thinkers, such as

Ways of Understanding 27 Kierkegaard (1983), who talk of the human desire to connect with that which is beyond our grasp. Psychological struggles result from the fact that we both desire but cannot possess the “more.” Even more prosaic psychological traditions, such as social cognitive theory (Bandura, 1976), are focused on constructs such as motivation. Understanding the Desiring Self through R/S Desiring as key to the self is found in several R/S traditions, of which we can only offer brief examples. The Hindu Vedas teach of how desire underlies all reality: “Thereafter rose desire in the beginning, Desire the primal seed and germ of spirit, Sages who searched with their heart’s thought discovered the existents kinship in the non-existence” (Ṛig Veda, Book 10, Hymn 129, Verse 4). From desire grows spirituality, reaching through our immanent world for transcendence. But desire is not always handled wisely. Buddhism notes how saṃsara, the cycle of birth, suffering, death, and rebirth, originates in the thirst of desire, which is nothing short of “the will to be, to exist, to re-exist, to become more and more, to grow more and more, to accumulate more and more” (Rahula, 1974, p. 31). Erotic desire is also a metaphor for the soul’s longing for God. The Sufi mystic Rumi opines, “I desire you more than food or drink. My body, my senses, my mind hunger for your taste . . . I wait with silent passion for one gesture from you” (1998, p. 34). Desire is foundational to ethics, as noted by the Jewish theologian Abraham Heschel (1951/1979): “What is first at stake in the life of the man . . . the primary task . . . is not how to deal with the evil, but . . . how to deal with needs” (pp. 180–181)? Finally, the Christian thinker Augustine describes the correct use of desire as the entirety of the spiritual life, noting that “you have made us for Yourself, O Lord, and our hearts are restless until they rest in you” (Augustine, 2009, p. 1). The metaphor of desire as quest also underlies any number of “secular spiritualities” (see Van Ness, 1996; Heelas, 2011), including inner life spiritualities (Heelas, 2008), holistic health practices (Fuller, 2017), social justice struggles (Hopkins, 1996), new metaphysicals (Bender, 2010), environmentalism (Dunlop, 2006), feminism (Levitt, 1996), and earth-based spiritualities (Deal & Magyar-Russell, 2018; B. Taylor, 2010). While outside the boundaries of traditional religious groups, these spiritualities echo their wisdom that spirituality is driven by longing for how things could be. In addressing the demands of desire, both R/S and psychological traditions need each other. R/S can speak to the correct ordering and ethical use of desire and the misery that comes from desire that burns for an object that it cannot have. Psychology can discuss the ways in which this misery comes about and how to address it. And both aspects are fair game for psychotherapy. For instance, a client struggling with a sense

28  Ways of Understanding of meaningless in their work might reflect more closely on the ways in which their Christian tradition talks about the tension between blooming where one is planted, doing good there, and taking the risk of following a call toward something different. The Relational Self The second aspect of the psychospiritual theme of the self is that of connection. Both psychology and R/S traditions consider human beings to be “intrinsically relational . . . connected with all creation and with one another, knit into the fabric of creation, and interwoven in an unfathomably deep and wide ‘living human web’” (Cooper-White, 2011, p. 39). The quest to become oneself requires walking an individual path, but it culminates in experiencing the self as an interdependent part of a greater interconnected reality. Therefore, in therapy, coping with the loss and challenge of relationships is a common theme. Understanding Relationship through Psychology Relationality is a basic category of theories of human development. For instance, Bronfenbrenner (2009) conceptualized the ways in which human beings grow and change through their reciprocal relationships with increasingly complex systems. Likewise, the attachment theory developed by Bowlby (2012) and refined by Ainsworth, Blehar, Waters, and Wall (2015) shows the long-term impact of caregiving relationships in early childhood. The central figure in family systems theory, Murray Bowen (1997), grounded his approach in the way each of us needs to negotiate a healthy balance of connection and independence through differentiation of self. This area is something that therapists are used to talking about. Understanding the Relational Self through R/S As familiar as relationality is through psychology, it is also at the core of traditional R/S understandings. For instance, the Christian doctrine of the Trinity, that God is three-in-one, suggests that being itself is characterized by communion (Zizioulas, 1997). Many thinkers (e.g., LaCugna, 2006) have taken this social character of the Trinity to entail that unityin-difference is the basic spiritual reality. Relationality is also essential to the central Confucian virtue of ren, true goodness: “Ren (仁) is constituted of two components, one for ‘man’ and the other for ‘two,’ indicating that a person can be ren—truly good—only in associating with others. . . . True goodness for Confucius is inter-relational, a virtue given realization only in a person’s interactions with other human beings” (Gardner, 2014, p. 25).

Ways of Understanding 29 In Buddhism, relationality deconstructs the concept of the Self. One of the cores of the Dharma is that there is no essential Self (anatta). Rather, all things interpenetrate one another through dependent origination. The monk Thich Nhat Hanh (1992) has called this interbeing: “There is a cloud floating in this sheet of paper. Without a cloud, there will be no rain; without rain, the trees cannot grow; and without trees, we cannot make paper . . . we can see the sunshine in it . . . as thin as this sheet of paper is, it contains everything in the universe in it” (pp. 95–96). No-thing exists by itself, all is interdependent relatedness. Interbeing reframes the family of things, revealed by any one moment, as a family of interrelated phenomena arising and passing over vast stretches of time. Not only does the idea of self as relational permeate a wide variety of classical R/S traditions, but it also is central to more contemporary understandings. For instance, the relational ideas of deep ecology (Barnhill & Gottlieb, 2001) derive from earth-based spiritual insights found in indigenous, Celtic, pagan, animistic, and pantheistic worldviews as well as major world religions. The ecological self belongs physically, emotionally, and spiritually to the ecology from which it came, is sustained, and will eventually return, known as Gaia (Taylor, 2010): one’s fellow human beings, all sentient beings, and the biosphere and cosmos itself. Deep ecologists maintain “we are natural beings, tied hand, foot, and heart to a vast web of natural beings that are, in a way, sacred” (Gottlieb, 2001, p. 19). Again and again, R/S traditions return to relationship as the basis of human reality. But relational difficulties are also behind all psychological problems. For this reason, therapy provides ample opportunity for expanding the understanding of selfhood through considering sacred reflections on interrelatedness. In realizing that connection is fundamental, a client can appreciate the broader significance of their struggles as universally human, and even come to new understandings of the self through engaging R/S wisdom. The Wise Self The final aspect of the psychospiritual theme of the self is as the locus of an innate wisdom that is oriented toward healing and wholeness. When cultivated through spiritual discipline, the wise self provides a view of the deep structure of reality, beyond the illusions and fictions that often cause our suffering. Contemporary authors describe this wise self as the soul: “Soul is not a thing but a quality or a dimension of experiencing life and ourselves. It has to do with depth, value, relatedness, heart, and personal substance” (Moore, 1992, p. 5). Soul is the connection between the psyche and transcendent Spirit (Hillman, 1992). The Wise Self is an image that deepens the significance of our psychological experiences and connects them to fulfillment in something greater.

30  Ways of Understanding Understanding the Wise Self in Psychology Inklings of this theme of the Wise Self are abundant in counseling theory. Most obvious is the Jungian use of the archetype of the Self as the key to individuation (Jung, 1980) and well-being, but there is also the integrated Self of transpersonal theory (Lukoff & Lu, 2005), the organismic valuation of the inner wise person (Rogers, 1961), self-transcendence (Maslow, 1994), the wise mind (Linehan, 1993), and mindful compassionate awareness of Acceptance and Commitment Therapy (ACT) (Hayes, 2004). In dealing with phenomena such as trauma, therapists seek to cultivate the wise self by clearing a space of stillness and quiet in the body to bring compassionate awareness to patterns of emotional suffering. These psychological understandings bridge to several traditional and nontraditional R/S ideas. Understanding the Wise Self in R/S Traditions The notion of connecting to a wisdom beyond one’s finite selfhood appears in many traditions. It is central to the Mahayana Buddhist sutras, which describe perfect wisdom as coming only when one trains oneself to confront the emptiness of all concepts for grasping the world: “The ultimate truth is that there simply is no such thing as a True Ultimate Reality, and the sooner we let go of such a thing the better” (Williams, 2009, p. 51). In this state, one sees things as they really are, realizing Buddha-Nature, a reservoir of wisdom. The Wise Self is also a central figure in Western Esotericism, a set of traditions coalescing in the late nineteenth century that attempted to find the underlying perennial philosophy underlying all religion (Hutton, 2006). Drawing from Abrahamic mystical writings such as Kabbalah as well as traditions such as Gnosticism, Hermeticism, Neoplatonism, and Theosophy, these streams of R/S stress secret knowledge and power gained through using occult tools to unveil the mystery behind how reality manifests itself. The basic assumption behind these techniques is summarized by the Hermetic writings: “If then you do not make yourself equal to God, you cannot apprehend God; for like is known by like” (Trismegistuss, 2002, p. XI). The self is wise because it is Divine. In addition to having influenced Jung and transpersonal psychology, these traditions manifest in contemporary movements such a neopaganism and the New Age movement. In all these traditions, Wisdom is seen as a transcendent dimension to which the self can connect through both disciplined effort and unexpected blessing. But it also is at its core about living life well, in a way that truly realizes how things are meant to be. Therefore, there is a conduit between deep reflection on the self and the pursuit of happiness, which has many connections to the idea of counseling itself. Here, wisdom is more about “how one knows” rather than “what one knows.”

Ways of Understanding 31 The Self as Psychospiritual Theme Desire, relationality, and wise-transcendence are three core qualities of the psychospiritual self. When damaged and disordered, they can become intimate sources of our deepest problems and challenges in life. Disordered desire has clinical implications related to addiction, and other habits of abuse, such as eating, shopping, internet, pornography, gambling, and work, among others. Damaged capacity for relationship may manifest in clinical issues, such as attachment problems, enmeshment, and a lack of meaningful relationships. Last, being cut off from inner sources of wise-transcendence could include chronic emotional dysregulation, meaninglessness, and a general inability to remain resilient in the face of everyday living. The word we use to encapsulate the full implications of these problematic processes is suffering, which we turn to next.

Suffering The reality of suffering is one of the most challenging and pervasive concerns of the human condition and few questions are more at the heart of the therapeutic process. Suffering is understood in many ways in R/S terms: as stagnation and enslavement, karma, attachment, a paradoxical path to transformation and freedom, as purification and as a social and interpersonal reality. Whatever its form, however, suffering threatens our sense of coherence, wholeness, and meaning. When significant and prolonged, suffering can lead to a pervasive sense of discouragement and loss of hope, and cause us to question if life is really worth living. It is worth wondering whether schools of therapy would ever have developed if human beings were capable of resolving all of their pain on their own. While it is true that much of suffering can find resolution outside of therapy, when those outside sources run their course, many clients come for help with a primary agenda in mind, simply put as “I am here because I don’t want to feel this pain anymore.” Extinguishing this pain is often a primary goal and an important metric of successful therapy. Thus, every theoretical school has developed a descriptive and prescriptive lexicon to answer why we suffer, what suffering means, what to do with suffering, and when we should expect it. Likewise, these questions cut to the heart of every R/S tradition and each has, at one time or another, confronted these questions with compelling ways of dealing with the problems that arise from the reality of suffering. For this reason, suffering is an unavoidable psychospiritual bridge. Understanding Suffering in Psychology There is a peculiar finding when surveying theoretical schools and how they approach the topic of suffering: rarely is the word “suffering” a

32  Ways of Understanding central or operationally defined term (Cappuzi & Stauffer, 2016). The R/S traditions appear more comfortable going to such depths. More common among Western psychological theories are explanations of how problems themselves develop and how making certain adjustments can ameliorate them—an approach centered on psychopathology. Each theoretical perspective tends to approach this cluster of questions in distinct ways. For example, as discussed in the exploration of the desiring self, psychoanalytic thought sees distress as the result of a conflict between instinctual desires and social mores, negotiated well or poorly by the ego (Johnson, 2016). There are some slightly different contours in the existential literature. Suffering, for many existential theorists, is framed in paradoxical terms in the sense of navigating and accepting the tensions inherent in the “givens” of existence (Yalom, 1980, p. 8), including death/life, meaning/meaninglessness, freedom/responsibility, isolation/ relationship, and authenticity/vulnerability. Rational emotive behavioral theory (REBT; Ellis & Harper, 1975) lays more heavy emphasis on the irrationality of belief (Vernon, 2016). Multicultural theories expand the scope of understanding suffering to include the contribution of systemic oppression (Sue & Sue, 2013). Understanding Suffering in R/S It is trivial to point out that each R/S tradition has a particular understanding of the psychospiritual theme of suffering. However, in contrast to the psychospiritual theme of Self, the way R/S perspectives have understood the theme of suffering is distinct from their Western psychological counterparts in the sense that R/S perspectives emphasize the transcendent dimension of suffering more emphatically. In R/S traditions, suffering has significance, even dignity (Taylor, 2007 that is missing from a more medical formulation. R/S approaches acknowledge that suffering commonly represents the greatest challenge to living as well as the greatest potential source of liberation. For instance, the Sufi Muslim poet Rumi would have us consider suffering “a guide from beyond” come to prepare the way “for some new delight.” Others, such as the Dharmic traditions of India, might focus on suffering as karma for a long-standing habit of wrong attachment across past lives. Still others, such as Christianity, prefer to view suffering as the consequence of sin. Lived experiences of suffering include all such conceptions. Though the lived experience of suffering itself is not always so clearly delineated, there are two broad ways in which suffering can be approached in R/S thought: (a) suffering of stagnation and enslavement and (b) suffering as transformation. These two broad categories of R/S suffering introduce a number of key ideas useful for conceptualizing clients’ core concerns.

Ways of Understanding 33 Suffering as Stagnation and Enslavement Sin Sin is one of the more common, though perhaps overly familiar—and therefore misunderstood—theistic terms for R/S suffering associated with stagnation and enslavement. Many find the vocabulary used in the language of faith deeply problematic today for nonreligious or religiously disaffected populations; terms, such as sin, feel old fashioned, carry repelling emotional baggage, smack of pious moralizing, and are grossly misunderstood. According to Norris (1998), words such as sin are “dauntingly abstract . . . even vaguely threatening” and so she concludes, “I had to rebuild my religious vocabulary. The words had to become real to me, in an existential sense” (p. 2). So what is the existential reality of sin as a lived experience? Across the various Hebrew etymologies of sin—to rebel (pasna), act wrongly (avah), go astray (chatah)—it can be summarized as “deadly alienation from the source of all life” (B. Taylor, 2000, p. 44). From self-inflation to self-negation, it is the experience of feeling locked out and cut off from “air, light, sustenance, community, hope, meaning, life” (B. Taylor, 2000, p. 44). Karma Similar to Abrahamic faiths discussed previously, the Dharmic traditions of R/S coming from India also “bear witness to the experience of a universal illness that has afflicted the human family from the beginning” (Keating, 2002, p. 152). The process underlying this universal suffering is karma. Karma is seen as an essential feature of reality in which all actions, from current and previous lives, necessarily beget more suffering or merit which become one’s destiny. It can take on fatalistic dimensions that prohibit choice as well as act as a source of hope for improving one’s future (Rahula, 1974). The cycle of birth, death, and rebirth, known as samsara, is the consequence of karma. As the law of universal justice, karma is the “womb from which we spring” (Thera, 1986, p. 248). As an individual experience, it is the self-perpetuating cycle of eternally sowing and reaping until one finds release in liberation and samsara ends. Stressing this cycle, the Upanishads (Isavassya) warn “those who worship ignorance (avidya) enter blinding darkness,” thus remaining ignorant of their true identity with the eternal reality of Brahman (Hopfe, 1979, p. 85). Common to both Western notions of sin and Eastern notions of karma is a general sense that suffering and blessing are related to human action. However, their differences are also significant in understanding a client’s lived experiences. For instance, a Hindu might think of negative life circumstances as the end result of bad karma from another life, something that a Muslim would not entertain.

34  Ways of Understanding Suffering as Transformation and Freedom It is important to understand that the theme of suffering is not entirely negative in R/S traditions. Buddhism understands suffering (dukkha) as inevitable in human existence, but as such, it is a “best friend” awakening the need “to do something about ourselves and show us where, when and how to do it” (Brazier, 1995, p. 13). Christianity considers suffering “the fire alarm that wakes us up to the possibility of true repentance” (Taylor, 2000, p. 47). Throughout the Sufi mystics, suffering is an inevitable, but valuable “stepping stone towards . . . perfection and spiritual growth” (Chisti as cited in Qadri, 1975, p. 41). Across the R/S traditions is a general teaching that suffering is a doorway to transformation. The long-standing tendency in psychotherapy to stress a diagnostic paradigm tends to obscure the opportunity that suffering poses. Important insights, such as “Not all breakdown is pathology, some break down is breakthrough” (Laing, 1960) are overlooked. Lamenting the tendency for psychotherapy to see suffering only as a mass of dysfunctional symptoms, Taylor (2007) wrote, “Within the culture of the therapeutic, the various languages, ethical and spiritual, in which this understanding can be couched become less and less familiar, less and less available to each new generation” (p. 622). The positive psychology movement (Seligman & Csikszentmihalyi, 2000) and research into phenomena such as post-traumatic growth (Tedeschi & Calhoun, 2004) have begun to re-open the idea that suffering is linked with growth. And here, these trends link with the insights of R/S traditions, which see suffering as a process of opening up. They teach that if we learn to approach it well, suffering is meant to give way to an unshakeable realization of unity, oneness, luminosity, and freedom. Suffering as a Catalyst for Justice Finally, suffering in R/S also speaks to the sociocultural realities embedded in and perpetuated by systems and institutions. If sin is being cut off from life, socially it looks like a system that cuts one off from the life of the community (Taylor, 2000). If attachment is being stuck, socially it looks like a system trapping people in a cycle of oppression and poverty (Rahula, 1974). R/S understandings of social suffering carry an implicit critique of social and cultural norms. Nowhere is this more apparent than in the Jewish prophets. Distraught by inequality, they give exasperated “orations about widows and orphans, about the corruption of judges and altars of the market place . . . the prophets take us to the slums” (Heschel, 1962, p. 3). They castigate for indifference to evil and warn of the consequences of worshipping false gods like learning, wealth, and might; not for joy of moralizing, but because idolatry foreshadows the destruction of civilization and the human species.

Ways of Understanding 35 To summarize the psychospiritual theme of suffering, we might think of it as inviting us to make a shift in our perception. While therapy typically enters into this theme through recognizing dysfunction in our lives, R/S traditions maintain that there is something deeper going on that has the potential to teach us wisdom. Psychological and R/S traditions can have conversation about the significance of suffering and how it is related to both mental and spiritual realities. As such, it is a common bridge that therapists might cross with their clients into realms that can be construed as part of one’s R/S. But as both psychological and R/S frameworks realize, we are not meant to stay in suffering; suffering moves us toward change.

Change R/S ways of understanding change and the process of growth are not so different from general psychotherapy. Both rely on the science of psychology to understand how human beings can work toward change. Both develop new ways of thinking, feeling, and behaving. Both aim for less suffering and more contentment. Even the ingredients for changing are similar—time, trust, patience, practice, and support. Empathy, unconditional positive regard, reworking core beliefs, radical acceptance, actualization, identity development, trust building, and earned secure attachments—all these concepts replicate, at least in part, meanings also found in R/S concepts of change. Three components of change in particular bridge between R/S and psychology: How does change happen? How does change unfold? and What is the epicenter of change? Change in Psychotherapy The idea of change is central to all therapeutic systems. Change is thought to come from a variety of sources: corrective emotional experience, processing unfinished business, changing from irrational to rational thinking patterns, changing conditioned responses, coming to tell a new story about one’s life. Except for some theories of psychoanalysis that have stressed insight, most of these psychological accounts of change are episodic. People change gradually, with consistent work and effort. Change also comes in stages of its own (Norcross, Krebs & Prochasta, 2011) starting in precontemplation, unaware of any actions to take, through the ambivalence of contemplation, into action and then sustained in maintenance. Psychological theories also vary considerably on the epicenter of change. On the one hand, cognitive behavioral therapy (CBT), behavioral therapy, REBT, ACT, dialectical behavioral therapy, narrative, and existential theory tend to emphasize cognitive awareness and mindfulness. On the other hand, emotion-focused therapy, Rogerian,

36  Ways of Understanding interpersonal process, and psychoanalytic theories aim at emotional catharsis and radical emotional attunement. Feminist and family theories aim for both as they relate to repairing socially and culturally oppressive systems. Meanwhile, trauma and other movement-based therapies highlight the primacy of working with the body alongside heart and mind (van der Kolk, 2015). The point of this very brief overview is change is dynamic and multidimensional; it occurs in fits and starts, stems from bio-psycho-social-cultural sources, and involves the mind, heart, and body of the human person. Change in R/S Traditions However, once we step over the bridge from psychology to R/S formulations, we see some additional ideas coming into focus. From an R/S perspective, change is not simply about making things more functional; it is also morally significant. Using R/S language, clients may refer to justification, forgiveness, surrender, redemption, repentance, liberation, submission, transformation, non-attachment, reconciliation, sanctification, etc. These are not simply different terms for otherwise similar processes already found in therapy. They constitute a change at the depth level of soul related to the wise self and how this self relates to transcendence. In R/S, change is not just the product of an isolated technique. Surrounding every meditation and prayer is a sacred narrative that brings moral, existential, and ontological weight to change. Techniques may focus on the individual, but they also connect with transcendent sources that allow us to change in ways we could not if left to our own devices. Themes of evil, damnation, affliction, and despair are modes of psychospiritual illness requiring equally potent interventions; concepts that speak to depths of the soul and understandings of ultimate reality. How Does Change Happen? Balancing Divine and Human Action Reams of theology circle the question “how does change happen?” For instance, theistic traditions puzzle over the role played by God—known as grace—and that of the individual. Balancing divine and human action for healing is a central R/S theme. We often see this dynamic illustrated in clinical situations. In his early research on R/S coping, Pargament (1997) identified three styles: selfdirecting, depending only on what one can do oneself; deferring, counting on Divine action to fix the problem; and collaborative, in which one works with the Divine to accomplish something beyond one’s own powers. This third option is distinct to R/S ways of understanding. It is seen in 12-step recovery programs in Step 2: “Came to believe that a Power

Ways of Understanding 37 greater than ourselves could restore us to sanity” (Alcoholics Anonymous, n.d.) and the Serenity Prayer: God, grant me the serenity to accept the things I cannot change, Courage to change the things I can, And wisdom to know the difference. (Alcoholics Anonymous, n.d.) Collaborative styles of R/S change implicate both psychological and spiritual processes. It aims at spiritual growth, but works through psychological processes. For instance, R/S change “does not force the ego to act, nor does it replace the ego’s proper function with a Divine activity . . . healing . . . is precisely to enable the ego to mobilize its own latent resources and direct them to purposeful action” (Meissner, 1987, p. 23). Connecting back to the psychospiritual theme of self, we might say change happens through the mobilizing activity of the wise self connected to transcendence. How Does It Unfold? Suddenly and Gradually R/S ways of understanding remind us that change may happen suddenly, as in instances of conversion and enlightenment, as well as gradually through practices such as yoga, healing prayer, and the eightfold path. Sudden experiences of change may involve an eruption of the numinous into one’s reality (Eliade, 1987). Awestruck and at a loss for words, these ineffable experiences foster change through sheer emotional intensity. Sudden experiences often resound in the psyche over the long term. James (1902/1936) wrote, “Some memory of their content always remains . . . and a profound sense of their importance. They modify the inner life of the subject between the times of their recurrence” (p. 292). Sudden spiritual change can entirely reorder one’s life. However, sudden experiences of change are not the norm, even within R/S traditions. Typically, spirituality involves developing practices that effect change over time. Each tradition prescribes its own unique path to sustainable change, such as the Hindu yogic paths, the Buddhist eightfold path, Christian teachings about imitating Christ, and spiritual disciplines of ancient philosophy. Positive psychology’s emphasis on cultivating and celebrating character strengths and virtues (Peterson & Seligman, 2004) as a gradual pathway to change resembles the intentionality found in R/S. Importantly, gradual change implies that there are ups and downs. Protracted periods of spiritual plateau may suddenly open to new depths. Spiritual practices effect change, almost imperceptibly, by healing wounds that disrupt the desires, relationality, and wise-transcendence of the spiritual self. In this way, suffering, change, and self are linked together.

38  Ways of Understanding What Is the Epicenter of Change: Heart and Mind, but Mostly Heart “The heart has its reasons of which reason knows not,” quipped Pascal (2018). However much R/S associate change with cognitive processes; it is the heart they are after. R/S ways of understanding suggest that our human condition is such that “our natural longing for a loving union with our Source lures us forward. The spiritual life comes to us not primarily as duty or argument but as desire and love” (Jones, p. 116). We are both thinking things and desiring animals, but it is the heart’s desires that determine what we think about. R/S change requires working with and re-educating desire. As Buddhist sage Nisargaddata remarked, “The problem with you is not that you have desires, but that you desire so little” (as cited in Kornfield, 2009, p. 199). In desire, the psychospiritual theme of change joins with those of self and suffering. In refining what we love, R/S traditions offer multiple pathways for achieving this goal. Not everyone is meant to follow the same set of practices for spiritual growth. One classic summary of the diversity of spiritual pathways is found in the Bhagavad-Gita, which describes multiple pathways toward ultimate release: jñāna yoga, the way of knowledge; bhakti yoga, the way of devotion; and karma yoga, the way of action, living out one’s duty and social function. Later traditions added the idea of experimental, esoteric practices, known as raja yoga or tantra. Different personalities, different stations in life, and different talents all can be taken into account when living a life of R/S practice. This is very important, because clients can sometimes approach this theme with the idea that there is only one, highly prescribed way to pursue the spiritual life. Spiritual and psychological change go together. We should expect then that discussing one will naturally lead toward discussing the other, and this is why it is a major psychospiritual theme. But change is not for its own sake. Change is meant to move us toward happiness, which brings us to the final psychospiritual theme we explore: flourishing.

Flourishing Flourishing has been a bridge concept between therapy and spirituality since the time of Ancient Greece, when philosophy was seen as a way of life that enables one to live a happy life (Hadot, 1995). Flourishing has to do with true happiness, and both psychology and R/S traditions have ideas on what happiness consists of and how to achieve it. Sometimes, the differences between these two frames create ethical conundrums, as we discuss in Chapter 7. But usually, the riches of both perspectives help shape clients’ goals for the therapeutic relationship.

Ways of Understanding 39 Psychological Perspectives on Flourishing As we discuss in depth in the chapters on intervening and ethics, psychology has always relied on ideas of human flourishing and health that move beyond the mere absence of symptoms. Developmental psychology, as illustrated in the work of Erik Erikson (1968), envisions each stage as posing a characteristic challenge that leads to the accumulation of strengths or deficiencies that impact later functioning. Maslow’s (1994) work on peak experiences and the hierarchy of needs suggests that human life is about more than just meeting an organism’s needs. Adler’s Individual Psychology (Sweeney, 2019) assumes that true psychological health is marked not just by the absence of distress, but also by the presence of social interest. Frankl (1992) prescribes finding a meaning for which one can live and die, rather than pursuing happiness outright. And building on these foundations, the positive psychology movement has constructed visions of happiness both in terms of balanced affect and in terms of living a good life (Ryan & Deci, 2008). These developments, familiar to many clinicians, have a momentum that brings them into contact with R/S discussions of human flourishing. R/S Perspectives on Flourishing One evocative description of R/S flourishing comes from the Christian author Irenaeus of Lyons, who says “the glory of God is a human being fully alive” (Irenaeus, 1872, IV.37.7). R/S traditions focus on what it means to be “fully alive.” The source that allows us to be fully alive may be located in capital “T” Transcendent reality (e.g., in monotheistic traditions), in lower case “t” self-transcendence (e.g., Eastern traditions), or in immanent or horizontal realities of transcendence (e.g., holistic health and earth-based spiritualities), and there are also many different understandings of the best or highest form of human life, but each R/S tradition must consider this vital question from the perspective of the individual, the community, and ultimate reality. Each R/S links flourishing to growing in the ability to experience and participate as part of a greater reality, however defined, both individually and communally. R/S perspectives on flourishing connect our own well-being with that of the cosmos. As such, they offer a richness that gives meaning to our lives and provides clients with language and ideas for moving beyond simply feeling better toward becoming who they were meant to be.

Using Psychospiritual Themes We have argued that psychospiritual themes are bridges linking psychological reflections to R/S ones. In the foregoing examples, we have tried

40  Ways of Understanding to provide some ideas for how these connections might look and the diversity that different client traditions may bring. A summary of the themes we have discussed can be seen in Table 2.1. We also realize that given the purpose of this book, we have elected to provide more of a tasting menu of the different traditions’ understanding of these themes than any satisfying main course. What then are the next steps for becoming proficient in this dimension of the Ways Paradigm for integration? First, we don’t expect clinicians to become experts in theology or religious studies, let alone in all the details of the major world religions. The important competency is to be aware of the kinds of topics (such as in Table 2.1) that can constitute psychospiritual themes and to become adept at using one’s listening skills to detect when clients are engaging them. Our client’s lived R/S should be our guide; the traditions they consider authoritative are ones we should build some familiarity with, led by the clients’ own formulation of psychospiritual themes. As we learn more, we can become better in helping clients make connections and see their experiences through both lenses. However, doing so ethically and competently requires additional reflection, which we explore in Chapter 7. It is also worth noting that additional skill in addressing psychospiritual themes is required for those whose scope of practice is pastoral counseling, especially when linked to a particular tradition. Scholarship in pastoral theology has considered the ways in which psychospiritual themes put questions to both psychological and theological understanding (see, e.g., Browning, 2010. In pastoral counseling, a deeper, more critical knowledge is required of the tradition as an “imagerial storehouse” (Gerkin, 2005) that can be drawn upon in response to the story Table 2.1  Examples of Psychospiritual Themes Theme

Subthemes

Clinical Illustration

Self

Desiring self Relational self Wise self Stagnation and enslavement Transformation and freedom Catalyst for justice Balancing divine and human action Suddenly and gradually Heart and mind, but mostly heart Individual Community Ultimate reality

The ways in which a substance use disorder can hijack one’s desires

Suffering

Change

Flourishing

Posttraumatic growth

Coping with a difficult health diagnosis

Trying to become generative at midlife

Ways of Understanding 41 of one seeking help. This is why formal theological education is usually considered to be essential to the practice of pastoral counseling. Case Study The case of Julian provides an example of how psychospiritual themes can arise in therapy. Julian is an evangelical Christian and first-generation Haitian American, born in Haiti to American missionary parents. He is an emerging adult (Arnett, 2014) and a recent graduate with a double major in sociology and Biblical studies. He has been struggling to bring the Biblical vision of justice to his first job out of college as an industrial painter. Julian spoke to the pastor of his church and completed several career and personality inventories at the local community college career center. Confused about next steps, he elected to see a therapist. Once rapport is built, you learn that Julian’s career struggles are related to his parents’ missionary work back in Haiti. Having seen the critical value of their work he feels guilty, restless, and anxious about the relative meaninglessness of his work. Compared with his siblings, who all work in ministry, he feels inadequate, estranged from his family, lost in his faith, and unsure about how and where the God he’s studied fits into his immediate world of work. His congregation is supportive, but he’s not finding much relief in their prayers. Many psychospiritual themes can help us understand the R/S dimensions of Julian’s situation. Julian’s guilt, anxiety, and isolation all represent forms of suffering resulting from parallel feelings of being cut off from his inner self, family, and the greater reality his tradition calls God. Yet, his response to seek counsel in his suffering suggests he is open to its transformative potential. Concerning the self, his desire for justice and relationship are currently unfilled. Also, his distress makes it difficult to access his wise spiritual self. His pathway to change might involve reframing his restlessness as a kind of grace, or whispering of the wise self guiding him to reevaluate his career path. As a proponent of social justice, he likely sees social justice work as a form of God’s grace in the world, but it is unclear whether he views grace coming through his current struggle. Feeling aimless in his faith, he may feel unsure if his restlessness could be the gradual, albeit unfamiliar way, of realizing deeper vocational aspirations. Given the estrangement he feels, it will be important to explore the dissonance Julian feels between his ideal forms of personal and communal flourishing, and the here and now of his immediate relationships to his family and church community.

Conclusion Ways of understanding lighten the reality of unbearable experience. They bring clarity able to help untangle clients from their maladaptive patterns

42  Ways of Understanding and cultivate growth. And yet they also hinder the ability to bear with reality—not because the understandings are inherently positive or negative, but because theoretical understanding itself only goes so far. Jung (2008) urged attention to this point when he wrote, “Learn your theories as well as you can, but put them aside when you touch the miracle of the living soul” (p. 361). R/S ways of understanding, ultimately, arrive at the paradox that the goal of knowledge is, in part, to understand the limits of knowledge, which is wisdom. Otherwise, theoretical knowledge alone may become yet another sophisticated defense used to bypass lived experience. For this reason, integrating R/S into therapy in ways that touch the miracle of the living soul depends not only on ways of understanding, but also on ways of being; those more embodied in presence and praxis, than grasped cognitively. To this dimension we now turn.

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Ways of Understanding 45 Kaufmann, W. (1974). The portable Nietzsche. New York, NY: Viking Press. Keating, T. (2002). Foundations for centering prayer in the Christian contemplative tradition. New York, NY: Continuum. Kierkegaard, S. (1983). Fear and trembling/repetition (H. V. Hong, Trans.). Princeton, NJ: Princeton University Press. Kornfield, J. (2009). The wise heart: A guide to the universal teachings of Buddhist psychology. New York, NY: Bantam Books. La Cugna, C. M. (2006). God for us: The trinity and Christian life. San Francisco and New York, NY: Harper. Laing, R. D. (1960). The divided self. New York, NY: Pantheon. Levitt, L. (1996). Feminist spirituality. In P. Van Ness (Ed.), Spirituality and the secular quest (pp. 305–334). New York, NY: Crossroad Publishing Company. Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder: Diagnosis and treatment of mental disorders. New York, NY: Guilford Press. Lukoff, D., & Lu, F. (2005). A transpersonal-integrative approach to spiritually oriented psychotherapy. In L. Sperry & E. P. Shafranske (Eds.), Spiritually oriented psychotherapy (pp. 177–206). Washington, DC: American Psychological Association. MacIntyre, A. (1981). After virtue: A study in moral theory. Notre Dame, IN: University of Notre Dame Press. Maslow, A. H. (1994). Religions, values, and peak-experiences. London: Penguin Compass. Maynard, E. A., & Snodgrass, J. L. (Eds.). (2015). Understanding pastoral counseling. New York, NY: Springer. Meissner, W. W. (1987). Life and faith: Psychological perspective on religious experience. Washington, DC: Georgetown University Press. Moore, T. (1992). Care of the soul: A guide for cultivating depth and sacredness in everyday life. New York, NY: Harper Perennial. Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of Clinical Psychology, 67(2), 143–154. https://doi.org/10.1002/ jclp.20758 Norris, K. (1998). Amazing grace: A vocabulary of faith. New York, NY: Riverhead Books. Pargament, K. (1997). The psychology of religion and coping. New York, NY: Guilford Press. Pargament, K. (2007). Spiritually oriented psychotherapy. New York, NY: Guilford Press. Park, C. L., & Paloutzian, R. F. (2005). Religion and meaning. Handbook of the Psychology of Religion and Spirituality, 2, 357–379. Pascal, B. (2018). Pensées (W. F. Trotter, Trans.). New York, NY: Dover. Peterson, C., & Seligman, M. P. (2004). Character strengths and virtues: A handbook and classification. New York, NY: Oxford University Press. Pew Research Center. (2015). Religious landscape study. Retrieved from www. pewforum.org/religious-landscape-study/ Qadri, A. (1975). The grace of contentment and surrender. Peshawar, Pakistan: Qadri Book Depot. Rahula, W. (1974). What the Buddha taught. New York, NY: Grove Press.

46  Ways of Understanding Richards, P. S., & Bergin, A. E. (Eds.). (2000). Handbook of psychotherapy and religious diversity. Washington, DC: American Psychological Association. Robert, T. E., & Kelly, V. A. (2015). Critical incidents in integrating spirituality into counseling. Alexandria, VA: American Counseling Association. Rogers, C. (1961). On becoming a person. Boston, MA: Houghton Mifflin. Rumi. (1998). The love poems of Rumi (D. Chopra & F. Kia, Trans.). New York, NY: Harmony Books. Ryan, R. M., & Deci, E. L. (2008). Hedonia, eudaimonia, and well-being: An introduction. Journal of Happiness Studies, 9(1), 1–11. Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5–14. Sells, M. A. (2011). Mystical languages of unsaying. Chicago, IL: University of Chicago Press. Sperry, L., & Shafranske, E. P. (2005). Spiritually oriented psychotherapy. Washington, DC: American Psychological Association. Sue, D. W., & Sue, D. (2013). Counseling the culturally diverse: Theory and practice (6th ed.). Hoboken, NJ: John Wiley & Sons, Inc. Sweeney, T. J. (2019). Adlerian counseling and psychotherapy: A practitioner’s wellness approach. New York, NY: Routledge. Taylor, B. B. (2000). Speaking of sin: The lost language of salvation. Cambridge, MA: Cowley Publications. Taylor, B. B. (2010). Dark green religion: Nature, spirituality, and the planetary future. Berkeley, CA: University of California Press. Taylor, C. (2007). A secular age. Cambridge, MA: Belknap Press of Harvard University Press. Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15, 1–18. Thera, N. (1986). The vision of Dhamma: Buddhist writings of Nyanaponika Thera (B. Bodhi, Ed.). York Beach: Samuel Weiser. Townsend, L. (2009). Introduction to pastoral counseling. Nashville, TN: Abingdon Press. Trismegistus, H. (2002). Hermetica: The Greek corpus hermeticum and the Latin Asclepius (2nd ed.). (B. P. Copenhaver, Trans.). Cambridge: Cambridge University Press. Ulanov, A. B., & Dueck, A. (2008). The living god and our living psyche: What Christians can learn from Carl Jung. Grand Rapids, MI: William B. Eerdmans Publishing Company. van der Kolk, B. A. (2015). The body keeps the score: Mind, brain and body in the transformation of trauma. London: Penguin Books. van Deusen Hunsinger, D. (1995). Theology and pastoral counseling: A new interdisciplinary approach. Grand Rapids, MI: William B. Eerdmans Publishing Company. Van Ness, P. H. (Ed.). (1996). Spirituality and the secular quest. New York, NY: Crossroad Publishing Company. Vernon, A. (2016). Rational emotive behavioral therapy. In D. Cappuzi & M. D. Stauffer (Eds.), Counseling and psychotherapy: Theory and interventions (pp. 364–395). Alexandria, VA: American Counseling Association.

Ways of Understanding 47 Weber, M. (1977). Max Weber: Essays in sociology (H. H. Gerth & C. W. Mills, Trans.). New York, NY: Oxford University Press. Williams, P. (2009). Mahayana Buddhism: The doctrinal foundations (2nd ed.). New York, NY: Routledge. Yalom, I. (1980). Existential psychotherapy. New York, NY: Basic Book. Zizioulas, I. D. (1997). Being as communion: Studies in personhood and the church. Crestwood, NY: St Vladimir’s Seminary Press.

3 Ways of Being

Best known for his 1957 article on the core conditions of therapeutic change, Carl Rogers never developed a formal system of spiritually integrated psychotherapy. As Rogers (1980) openly admitted, he vacillated between an enmeshment with fundamentalist Christianity in his childhood, to a formal disengagement and disillusionment with the power of religion to provide meaningful answers to life’s problems at Union Theological Seminary in Manhattan, to something of a reengagement with world religions later in life. However, the following quote would certainly lead you to believe that he was heading in that direction and was discovering the power of spiritual themes to create a dynamic and, in his words, healing presence: As a therapist, I find that when I am closest to my inner, intuitive self, when I am somehow in touch with the unknown in me, when perhaps I am in a slightly altered state of consciousness in the relationship, then whatever I do seems to be full of healing. Then simply my presence is releasing and helpful. There is nothing I can do to force this experience, but when I can relax and be close to the transcendental core of me, then I may behave in strange, and impulsive ways in the relationship, ways which I cannot justify rationally, which have nothing to do with my thought processes. But these strange behaviors turn out to be right in some odd way. (Rogers, 1986, pp. 198–199) These words, taken from a chapter published shortly before his death in 1987, are pregnant, to say the least, with spiritual themes which we have covered in the previous chapter. More importantly, for this chapter, Roger’s description of his work with his clients makes a qualitative leap from our previous focus on the content of R/S in therapy, with its necessary and important focus on the “what” of integration, to the process of “how” these realities are experienced in the here and now of therapeutic encounters. The “what” and the “how” of bringing religion and spirituality into therapy can, if rightly understood, never be separated out

Ways of Being 49 from each other—one implies the other. It is worth considering that, in context, when Rogers gave that rich description of his transcendent experiences in therapy he was talking about his experience of empathy for his clients. He went on to say that it was really empathy In its highest form, again using almost formal theological terms, of literally “indwelling in the client’s world” (1986, p. 206). This will, of course, remain relevant when we consider the “what” and “how” to intervene using psychospiritual techniques; as much of contemporary evidence-based practice research has recognized and reaffirmed, counseling implies embodiment (Norcross, 2011). The core facilitative conditions of change are not so much things counselors do to their clients as they are ontological modes (how our being is known and understood) that form the therapeutic relationship which in turn are experienced as presence (Cooper, 2017). This raises the vital question about how does a counselor embody a healing presence?

Ways of Being across Theories Cheston (2000) acknowledged that exactly what way of being a therapist will adopt is slightly different depending upon what kind of theoretical assumptions are at work. Thus, psychoanalysts may stress a neutral stance to evoke projective material to be unpacked; behaviorists may intentionally utilize nonverbals to reinforce learning; REBT specialists may see the relationship as a technician who approaches the relationship by solving the most immanent problem first; while Gestalt therapists will stress the here and now. Alternatively, there may be differing styles within theories such as family experts who focus either on remaining as a neutral interpreter to prevent triangulation and smooth out family communication or as a joiner who uses the family’s relational style as a means of intervention. More recent transtheoretical perspectives approach relational style pragmatically by focusing on matching relational patterns with clients based upon what evidence may support. So, if a client is passive, a more active way of being could be more effective and vice versa for a client who is self-directive (Norcross, 2011). There is likely no single way of being that is going to be effective in every relationship. While a therapist’s way of being may be in part influenced by their theoretical perspective, we have good evidence that Rogers was right: the core conditions for change require the counselor to embody empathy, unconditional positive regard, and genuineness (Rogers, 1957; Norcross, 2011). However, how the core conditions come to be and exist in a helper and the relationship they develop with a client implies formation, an intentional process of being shaped into a particular kind of person who acts in a certain way. This, in short, is what Cheston (2000) described as a counselor’s way of being, “who the counselor is, the degree of empathy expressed, the values the counselor demonstrates, the boundaries that are

50  Ways of Being set, [and] the importance’s ascribed the relationship” (p. 256). In helping, it is not enough to be a person, rather it is this person who has been put together in this way that emanates a particular way of being which is experienced as healing. However, these ways of being take on new meaning when placed into the context of R/S.

Transcendence and Immanence There are two basic ways of describing R/S experiences. While one focuses on R/S experience as transcendence, and the other focuses on immanence, both are foundational to experiential knowledge. Rudolph Otto (1923), in a book called The Idea of the Holy, surveyed religious traditions studying their sacred texts and teachings which described foundational R/S experiences such as Moses and the Burning Bush and Buddha’s teachings on Nirvana. He noticed some basic similarities across these transmuted descriptions about how these foundational figures experienced such realities despite each tradition giving a different name to them like Heaven, Nirvana, God, the Burning Bush, Moksha, etc. Otto’s (1923) phenomenology focuses on the transcendence of what he referred to as the Holy— holy not as in moral perfection, but as wholly other. Whatever this is, it is something that is transcendent and goes beyond the human psyche. He called the object of this common R/S experience the numinous. The numinous, according to Otto, can be understood and described using the Latin phrase mysterium tremendum et fascinans, the mystery that causes both fear and fascination. On the one hand, the numinous causes a sense of what some R/S call holy fear, or a sense of great awe. This is not a fear of annihilation, rather it is a sense of overwhelming grandeur. The other side of the numinous is a sense of almost overpowering attraction. What makes the numinous distinct among human experiences is that it brings about these two sets of conflicting emotions simultaneously. William James (1902/2003), in his seminal work The Varieties of Religious Experience, also looked at R/S experience across traditions, but in his case, James utilized case studies of individuals who were identified as mystics. Like Otto, James found that there also were common ways mystics talked about their R/S experiences, but for James that took on a different emphasis. He discovered that there are four common factors of mystical experiences. First, they are ineffable—language cannot fully encapsulate R/S experience. Second, they are noetic—they transmit a sense of knowing or truth, particularly of significant sense of being in unity or one with ultimate reality. Third, they are transient—these moments do not last for long but come and go. Last, they are experienced passively—they have a sense of something being done to oneself, rather than conjuring up the experience with intentional effort. James’s discovery of common factors of mystical experience stressed the immanent or

Ways of Being 51 the unitive quality of these experiences. In contrast to the numinous, these experiences revealed an R/S phenomenology very close to the center of the human psyche itself. Beyond Words It should become evident at this point that trying to describe R/S experience along with a therapist’s way of being stretches the limitations of human language to its breaking point. Without papering over how different traditions interpret the experience of either the numinous or mysticism, there are some noticeable similarities between how these eminent scholars describe R/S experience and how Rogers described his presence and experience with the Other. In fact, the way these moments are felt in therapy are evocative of the phenomenology of R/S experience. So, when Rogers (1986) said that his presence becomes a qualitatively different mode of being and he is closest to his “transcendental core” (p. 198), he was describing a way of being that actually finds its origins in R/S experience. The Tacit Dimension It is also true that in describing ways of being we are trying to describe something that often functions outside of our awareness, automatically or intuitively, and is packed with layers of meaning. Much of what happens in therapy is actually happening outside awareness. Anyone who has reviewed their clinical work with an intentional reflective tool like interpersonal process recall (Kagan, 1980) is likely to unearth layers of meaning that were not even noticeable in real time. This is consistent with how the chemist and philosopher Michael Polanyi (1966) understood the nature of being. Polanyi’s basic thesis about human knowledge was that the nature of knowledge or “knowing” is deeply embodied, rather than being a detached and abstracted rational process. We know “more than what we can tell” (Polanyi, 1966, p. 4). What we “know” and who we are right here, right now (i.e., our being) are nearly synonymous. It is something profoundly experiential and is therefore developed and transferable through being. He said: We must now recognize belief once more as the source of all knowledge. Tacit assent and intellectual passions, the sharing of an idiom and of a cultural heritage, affiliation to a like-minded community: such are the impulses which shape our vision of the nature of things on which we rely for our mastery of things. No intelligence, however critical or original, can operate outside such a fiduciary framework. (Polanyi, 1962, p. 266)

52  Ways of Being This fiduciary framework to which Polanyi refers is one of belief (or knowing) derived from one’s tradition (Mitchell, 2006). Traditions, whether R/S or otherwise, are passed down through generations up to the present and form the matrix of knowing, both its potentialities and its limitations. These transgenerational transmissions of knowledge form the tacit layer of our experience which are the starting positions for our rational processes of knowing. In other words, tacit, unarticulated belief precedes conscious reasoning (Polanyi, 1966). Much like, he says, “We know a person’s face, and can recognize it among a thousand, indeed among a million. Yet we usually cannot tell how we recognize a face we know” (Polanyi, 1966, p. 4). Thus, contrary to the modernist notion of knowledge detached from subjectivity, or seeing knowledge as something we bring into our mind, as it were, from the outside like pouring water into a vase, Polanyi proposed that the subject-object dualism was impossible such that: The establishment of truth becomes decisively dependent on a set of personal criteria of our own which cannot be formally defined. . . . The ideal of an impersonally detached truth would have to be re-interpreted to allow for the inherently personal character of the act by which truth is declared. (Polanyi, 1966, p. 71) In other words, deep interior and intuitive knowing precedes rational abstract thinking. It is in our bones. More importantly, all knowledge requires a complex interplay by alternating between one’s intuition and rational calculation. This frames the process of discovery in fields such as the sciences where learned experts develop their finely tuned hypotheses and experiments as well as the absorption of knowledge by students in established fields of study who are neophytes. This would be true of applied fields, like therapy, as well. In practical terms, counseling skills (how we know what to do with a client) require a similar framework as they are not possible to reduce down to a set of explicit rules. Rather, skills are shaped through a process of indwelling a teacher’s example (Polanyi, 1966). The relationship between master and novice is one based on a basic belief and trust in the master’s teaching, without a complete understanding on the part of the novitiate of the full tome of praxis. The master may do things or invite the novice to practice before the meaning is grasped in the hope that practicing the skill will teach the meaning of the skill. Anyone who has experienced clinical supervision with an advanced practitioner has likely experienced this sense of the supervisor’s knowledge “rubbing off” onto their practice (Young, 2015). It would also be true that Polanyi’s insistence that knowledge is passed through the master-novice paradigm would apply to relationships which exist in the context of R/S traditions, where the focus is on the development of

Ways of Being 53 character virtues and the transformation of the self (see Chapter 2). The archetypal figures of the sage, guru, prophet, spiritual teacher, or wise counselor, who intensely mentor and pass down knowledge to their disciples, all would be examples of Polanyi’s thesis. Polanyi’s take that all knowledge is deeply formed out of our tacit dimension is invaluable for understanding ways of being from the standpoint of R/S integration. To begin, Polanyi’s concept of the tacit dimension abolishes the notion that therapists can approach R/S topics detached from the issues themselves; this is true of therapists who personally inhabit an R/S tradition as well as those who do not. No therapist can be sectioned off from their ancestral or cultural lineage. While not everyone would acknowledge a transcendent dimension to their way of being, even therapists who do not claim a traditional R/S identity still have negotiated the givens of existence over the course of their lifetime, including the tensions that exist between being and non-being (Yalom, 1980), which have formed their dispositions. For those who have been formed out of an R/S tradition(s), the tacit dimension is equally at play, while, obviously, the practices and the purpose for which they take shape may look different. Thus, while atheistic and theistic therapists may both engender a way of being that ultimately alleviates the psychological pain of their client, the former may do so because they wish to see less pain in the world while the latter views it as fulfilling a divine call to love one’s neighbor as oneself. However, not to acknowledge the hidden factors at work which developed their dispositions, different as they are from each other, would seem naive. Though all therapists must be pragmatists, they bring a tacit layer of philosophical assumptions with them into every applied scenario. The tacit dimension, then, is the evolutionary process of knowing which is expressed as the therapist’s ways of being. We assert that this tacit dimension is part of who a therapist is, whether one realizes it or not. Arguably, one of the values of clinical supervision and personal therapy is to actually bring this realization from the background of our consciousness into the foreground where our way of being can be finely tuned so as to develop a healing presence. These dispositions vary in their consequences, but they form both a therapist’s strengths and liabilities for connecting with their client: Indeed, they make connection with a client either probable or impossible.

Buber’s “I and Thou” and Relational Depth The tacit dimension is the potential for real connection between persons, but how that connection can be understood requires nuancing. To start, think of a moment working with a client in which you felt that the relationship had ventured into new and uncharted territory—when whom the client was suddenly became known to you. Up until that moment,

54  Ways of Being everything seemed like preparation for what would happen when you felt that sense of deep relating. At this moment, you really felt like the person sitting across from you let their guard down, their defenses were finally laid aside, and you simply knew that who they were was fully present. Not only that, who you are was totally present to them as well. At that moment, there were simply two persons, seeing into the other. These moments come and go in therapy; rarely do they stay for very long. They are also powerful, and potentially life-altering. They are what the Jewish philosopher, Martin Buber (1970), called the I-Thou encounter. In a thought-provoking word play on the opening lines of the Book of Genesis and the Gospel of John, Buber claimed that “In the beginning is the relation” (p. 69). Of course, Buber was making a descriptive assertion about the nature of ultimate reality as innately relational, that life involves and is ordered by relationship, a theme we revisit toward the end of this chapter. But in his seminal work, I and Thou, Buber identified two possible ways of conceptualizing the way human beings, as subjects, relate to other people and their world. Both of these types of relationship are fundamental modes of human existence, or as Buber (1970) said, our world is “twofold in accordance with man’s [sic] twofold attitude” (p. 53). The first attitude is what Buber (1970) called the I-It relationship. This kind of relationship is developed as a subject relates to objects. Objects by definition, are parts; they are limited expressions of a whole. Buber made this crucial distinction by examining human attributes. For instance, people can become a series of Its by simply describing their parts, the color of their hair or eyes, their height or weight, sex or gender, or their psychological attributes such as their personality or behavioral dynamics. Thus, a therapist, using Buber’s insights, can relate to their clients very quickly and easily as objects—for instance, as the borderline client or the identified patient. The second, which lies latent to the first, is how therapeutic ways of being may be conceptualized; they are what Buber (1970) called the I-Thou relationship. The change of the stem from It to Thou is a qualitative shift of modes of existence. Instead of relating to parts of a whole (the Its), one relates to the whole, or as Griffith and Griffith (2012) would say, whole person to whole person relatedness. In therapeutic terms, this type of relating to a client is characterized by deep knowing, where who the client really is emerges, and this involves not a diagnostic categorization, but an opening up of encounter between therapist and client, when the whole person emerges from the background into the foreground of conversation. For Buber, the “I” in this relationship is vital for such relationship to emerge. It is not an “I” of ego, meaning this subject does not require differentiation from other individuals. This is the mode of existence of the I-It relationship. Rather, it is the “I” of personhood, or subjectivity, and appears only when the person relates to other persons. The former is a natural mode of existence; the latter is spiritual.

Ways of Being 55 If Buber’s phraseology of the I-Thou relationality can be viewed as a given in therapy, where relationship is a fundamental framework for approaching therapeutic change, then it would make sense to explore what other dimensions emerge under this assumption. One theme is the concept of relational depth. Some years ago, the transactional analyst and Jesuit priest John Powell proposed that there are modes of relational depth in human encounters expressed through qualities of communication. Powell proposed five levels of communication (small talk, factual conversation, ideas and opinions, feeling and emotions, and deep insight), with each deeper layer of communication requiring more vulnerability and therefore incrementally stronger trust between persons to express. Powell’s framework matches well with contemporary counseling skill theory that facilitative dispositions and interventions increase deep communication (Young, 2017). According to Lazaraus (1981), it is often in these deeper, subterranean layers of the client’s life where significant therapeutic transformation takes place, and it is unlikely that meaningful change will occur without making contact at such depth. A contemporary effort to put more concrete descriptors onto the I-Thou encounter is David Mearns’ concept of relational depth, which can be defined as “a state of profound contact and engagement between two people, in which each person is fully real with the Other, and able to understand and value the Other’s experiences at a high level” (Mearns & Cooper, 2005, p. xii). Mearns and Cooper (2005) proposed that relational depth occurs when all six of Rogers’ (1957) facilitative conditions were put into effect. At the same time, however, this encounter goes beyond them to include psychological qualities of “intimacy, mutuality, presence (genuineness, openness, and engagement by both parties), affirmation (a ‘reaching out to the client’s otherness’), and ‘meeting without words’ or close mutual communication and attunement with the other” (Wiggins, Elliot, & Cooper, 2012, p. 140). Though experiences of relational depth between a therapist and their client may be positive, they are not by default mere sentimentality; these encounters imply vulnerable risk-taking and therefore may be frightening for both parties. This is perhaps why Powell chose such a provocative title in exploring the concept when he wrote his book Why Am I Afraid to Tell You Who I Am? The answer at this point should almost be rhetorical. Revealing the self is a risk that the self will not be embraced by the other, and instead will be rejected. Using Rogers and Mearns as guiding theorists, Wiggins and colleagues developed a five-factor model of relational depth, with each factor representing themes covered so far. One factor, in particular, is relevant for our discussion because it captured a dimension of relational depth experiences that are described as moments of transcendence. Again, the primary works of Western psychological mysticism of James (1902/2003) and Otto (1923) find relevance, because items on this factor describe moments of relational depth such as a suspension of time,

56  Ways of Being silence and stillness, going beyond the ordinary, awe, and love. Though strongly correlated with a healthy working alliance, experiences of spiritual transcendence and relational depth more broadly can be thought to represent an “upward extension” of the therapeutic relationship, and tap into “a different region of the relational continuum” (Wiggins et al., 2012, p. 151). Thus, one way of viewing the therapeutic relationship can be as a context or structure, much like a sacrament in Western theology, that provides a passageway to the transcendent. The quotation from Rogers’ (1986) words which started this chapter, then, were somewhat prophetic of scientific exploration of being in therapy, as he seemed to intuit from his experience some of these deeper and more profound states of being in relationship. To make this point even more explicit, these states of being are what Pargament, Lomax, McGee, and Fang (2014) would call “sacred encounters” that are characterized by transcendence, ultimacy, boundlessness, interconnectedness, and spiritual emotions. Take, for example, the following description Pargament et al. (2014) collected from interviews with therapists who had experienced sacred encounters: My client has been addicted to narcotics for over 20 years. He wished he could talk about it with his mental health providers but did not feel comfortable with any of them. He was very ashamed of it and thought he had betrayed my trust by not disclosing it earlier. He said I was different than all other providers in the sense that I was genuinely caring about him and paying attention to what he was saying and also to what he was not saying. It was like time had stopped and we were two vulnerable human beings connected at a very deep level. A “sacred” moment. (p. 252) Importantly, these moments are not uncommon in therapy, are not dependent upon the religiousness of the client or therapist, and when they are experienced, have positive effects on the therapeutic relationship and on the client’s well-being.

The Liminal Space and Intersubjectivity Relational depth could be thought of as something of a watershed moment in the reinvigoration of exploring ways of being in therapy, deeply grounded in first-person experience, yet incorporating the methods of social science to further map out the terrain of relationality; relational depth taps into a unique dimension of therapeutic experiencing. In addition to the relevance of transcendence to depth, Wiggins and colleagues (2012) also found that vulnerability was an important factor of relational depth, accompanied by experiences of fear, conflictual emotions, paradoxical truths, and sensation that are foreign or weird.

Ways of Being 57 This experience of vulnerability in therapeutic relationship is similar to how the British anthropologist Victor Turner (1969/2017), in his work The Ritual Process: Structure and Antistructure, described the concept of liminality. The process of ritual or rites of passage involves, according to Turner, three distinct phases. Though often encountered in distinctly religious contexts, ritual can also be a broader description of the process of change itself, and therefore is relevant to any profession which specializes in enacting change. The first, separation or preliminal, refers to the detachment of an individual or group of individuals from their existing social structure, or really any fixed point through which they have come to inhabit such as a stage of psychological or spiritual development. The second, margin or liminal (or limen in Latin meaning “threshold”), is a period of ambiguity in which the subject or person is in state of “betwixt or between” their typical network of identity given by “law, custom, convention, and ceremonial” (p. 95). Liminality is a time and space of transition, between what was and what will be, while possessing none of the attributes of either past or future states. Because of its ambiguity, liminality is often characterized by rich symbolism as being born, transparency, non-possession, absence of light, gender and/or sexual ambiguity, the desert or wilderness, or celestial pivot points (e.g., eclipse of the moon or sun). The Franciscan Richard Rohr (1999/2003) said about the liminal space that: There alone is our old world left behind, while we are not yet sure of the new existence. That’s a good space where genuine newness can begin. Get there often and stay as long as you can by whatever means possible. . . . This is the sacred space where the old world is able to fall apart, and a bigger world is revealed. (p. 155) It is also at this point of transition that the initiate experiences communitas (the Latin word for which we derive “community”), a deep solidarity with all fellow initiates regardless of social hierarchy. Indeed, in the liminal space hierarchical structure dissolves, leaving a profound humility in its place. This passage through the liminal period is followed by a third phase of reaggregation or reincorporation, a new person has emerged (hence the analogy of gestation) with a relatively stable set of identity features and understanding of new roles and obligations in their social scheme. This entire process (from preliminal, liminal, and reaggregation) is typically facilitated by a person or persons who serve as the overseer(s) of change from one state or stage to the consummation of the ritual. As we said, while Turner (1969/2017) was studying the process of rites of initiation from the standpoint of an anthropologist, therapy (or any change process) follows a similar scheme. In her article suitably titled “Ritual as Therapy, Therapy as Ritual,” Davis (2000) noted several

58  Ways of Being corollaries between what religious communities have done for millennia in ritualizing various times and places of human development to how therapists ultimately lead clients through a ritual of sorts. For instance, both religious ritual and therapy involve “public, structured occasions with prescribed formats, actions, and mutually agreed upon roles” which ultimately follow the tripartite process framework discussed by Turner (1969/2017). In the preliminal phase, the therapist hears the client’s description of the presenting problem (intake, rapport building, treatment planning) through telling of story. In the process, the client removes the typical social structures which they are accustomed to, for instance sharing personal information with someone whom they have just met. In the liminal phase, the therapist interjects (through various interventions) and engages the client in transformation of the meaning of the story itself and new perspectives begin to emerge. Of course, those characteristics of what makes the liminal phase both possible and productive hold true (e.g., deepening trust through therapist facilitative skills). This is probably why humanistic-existential theorists downplayed the role of expert and favored instead genuineness which comes from a deep rootedness of the therapist’s identity whereby a need to prove hierarchical superiority is both unneeded and counterproductive. Thus, to enter the liminal phase requires a humility, a decentering of fixed features of identity and hierarchical status between client and therapist, where both parties see each other as true equals in their humanness (O’Grady, White, & Schreiber-Pan, 2015). Developmental theorists in both clinical and educational contexts have recognized the importance of embracing the discomfort and ambiguity that stands between states and stages of change (Prochaska, Norcross, & DiClemente, 2007), and this is particularly true for the formation of effective helpers (Stoltenberg & McNiell, 2010). The concept of liminality most closely aligns, from the client’s standpoint, with the betwixt and between characteristics of the contemplative stage of change, wherein the client has neither fully embraced the need for change nor are they content with the status quo. This is, of course, followed by the planning, action, and maintenance phases which all in some shape or form represent a state of reaggregation where the client incorporates their newfound perspective to their original predicament and leaves therapy changed, ready and empowered to confront the demands of their friendships, families, and communities. To draw together the insights of the previous section, something curious happens during the liminal period of both ritual and therapy as it pertains to relationship, what philosophers would call intersubjectivity. Three of the most notable philosophers of intersubjectivity, Husserl, Buber (whom we have already covered), and Hegel, each proposed unique positions on the concept that defies simple reductionism. However, Crossley (1996) distilled two major dimensions put forth by these thinkers. The first is the intersubjectivity most commonly attributed to Buber’s I-Thou and I-It typology, which could be called a radical intersubjectivity and

Ways of Being 59 which hinges upon unconditional openness toward the other that lacks self-preoccupation. The second, derived from Husserl, is an empathic intersubjectivity in which otherness is traversed by means of imaginative transposition of the self onto the other, similar to Rogers’ definition of empathy as a sense of the other’s inner world as if it was your own “without ever losing the ‘as if’ quality” (Rogers, 1957, p. 99). What these perspectives suggest and hold in common is that it is possible for people to transcend the separate self (the ego) and be united in a shared existence with others.

The Analytic Third During the experience of liminality in therapy, in which intersubjectivity becomes most acute, and while indeed there is a real sense that barriers between souls are broken down, there at the same time is a sense that there is more “present” in the room than just the client and the helper. Object relational theorists have referred to this sense as the “analytic third” (Ogden, 2004). As Cooper-White (2007) explained, as the degree of vulnerability and intimacy increases in the therapeutic relationship, it is filled with “images, fantasies, thoughts, feelings, and sensations as the intersubjective relationship grows” (p. 233). This growing pool of consciousness is made up of parts from the therapist and parts from the client, so that “This pool itself, then, may in some ways take on a life of its own as a third subjectivity in the room . . . something that is perhaps greater than the sum of the many multiple parts that constitute both partners” (p. 233). The analytic third is made up in part of both the therapist and the client, yet goes beyond them at the same time. Though originating from a Neo-Freudian perspective, the analytic third is nevertheless a concept that touches on R/S ways of being, which in some ways enlivens it with a transcendent dimension. As Cooper-White (2002), in quoting Martin Buber, asserted: “From a theological perspective, this shared knowledge participates in the ‘infinite conversation’ of which Buber wrote: ‘Extended, the lines of relationships intersect the eternal Thou’” (p. 55). Later, Cooper-White (2007) further extrapolates about this R/S connection when she says: This is perhaps where the pastoral psychotherapist has an advantage. The language of non-possessive, compassionate love permeates Judeo-Christian scriptures . . . sometimes it is precisely the hope, the faith, and even the fascination with the therapeutic process itself—in a sense the love of the analytic third, that is the therapy—that carries forward the therapist’s care and compassion. (pp. 244–246) This is not far off from how Carl Rogers, in his dialogue with the influential Lutheran theologian Paul Tillich in 1965, described the core

60  Ways of Being facilitative conditions for change (Rogers, Kirschenbaum, & Henderson, 1989). In a fascinating discussion covering a wide variety of expansive topics from the nature of the human condition, personality theory, atheism and theism, to the meaning of religious symbolism, Rogers and Tillich eventually came to the core of Rogers’ theory of change and optimal human functioning. They came to alignment that what Rogers would call the core conditions—empathy, congruent, and unconditional positive regard—is what Tillich called listening love, grounded in the conception of Christian agape. Thus, the experience of deep relatedness in therapy breaks way to the spontaneous experience of transcendence. Or as Carl G. Jung’s epitaph on his tombstone reads: “Bidden or Not Bidden, God is Present.” The experience of the I-Thou, relational depth, intersubjectivity, and the analytic third, related as they are, all represent what kind of therapeutic encounters can develop through an effective way of being or healing presence. At the same time, they demonstrate “how thin the membrane finally is between the ‘faith’ of secular therapy and religious faith” (Cooper-White, 2007, p. 241), especially when it is grounded in an experiential, first-person, encounter. It is now time to answer the question: How is a way of being cultivated, developed, and/or sharpened? The two major contributors to which most experts in the helping fields will likely put forward are personal therapy and supervision. These are welcomed responses to be sure. While these are more or less standard answers, how ways of being are influenced can also be significantly informed by the emerging field of contemplative psychotherapy that finds its origins in R/S being.

Contemplative Psychotherapy Contemplative practices involve a diverse array of methods intended to cultivate an intentional and compassionate way of living that originates from a deep centeredness and can involve engaging the mind and/or body in specific exercises that range from direct experience of the self as object to focusing of the mind on complex phenomena (Barbezat & Bush, 2014). We use the term contemplative and its derivatives here as inclusive of the term meditation, while also distinguishing the fact that contemplative practices originated within the world’s wisdom traditions. In that sense, Western secular meditation is a relatively recent phenomenon compared with this larger socio-historical context in which contemplation originated and is practiced globally. Therapists have embraced contemplative practices in their work and the numbers of therapists who also practice something like mindfulness or a related meditation have become widespread. This ever-increasing popularity has given rise to a distinct subdiscipline, called contemplative psychotherapy, where the principles

Ways of Being 61 of ancient methods of religious mysticism are brought into conversation with Western professional helping paradigms. As with most psychospiritual phenomena, there are a variety of ways and means to define a word such as contemplation. However, one of which we are most fond and find practically useful is the definition posed by the Jesuit Walter Burhgart (1989) who said that contemplation is a “long loving look at the real” (p. 15). This pregnant phrase offers several important clues into what contemplative practices aspire to develop. First, there is a time element; it is a slowing down of the typical pace of life and an intentional non-hurried posture is developed. Second, it is loving; this includes both the cultivation of compassion and altruistic motivations, while lacking the tone of mere sentimentality often associated with the word in Western English. Instead, love is the highest state of being for many religious traditions. Next, it involves the sense of seeing. This can, of course, involve the eyes of physical sight, though it probably is better understood as a deeper aspect of apprehending the nature of reality as it is held in one’s gaze. The real then is an unearthing of ultimate being, the nature, so to speak, of things. Contemplative practices often have this end in mind. Though we explore the therapeutic implications for the client of such practices more fully in the following chapter, the dispositions which contemplative practices engender in those who dedicate themselves to them are relevant to the formation of therapists. In essence, these practices are intended to develop a way of being that is consistent with the highest ideals of living. Ideals that lie at the heart of R/S formation, such as love and compassion, are simultaneously highly valued by the helping fields. Contemplative practices are not always embraced by the helping fields along with all of the nuances that their R/S traditions provide. However, these rich, millennia-old perspectives are becoming more relevant to these professions as their practical value is becoming more apparent in mainline psychological care. So we begin with a fairly familiar starting place for many, that is, how mindfulness changed how Western psychology viewed the relevance of contemplative practices to ways of being, and branch out from there to Western R/S contemplation, which remains largely untapped for its insight into therapeutic ways of being. Mindfulness and the Meditation Revolution in Therapy With the publication of Full Catastrophe Living in 1990, a very old term became somewhat novel in medical and psychology circles; now years later it has become something of a household name (Neal, 2017). That term is mindfulness. The medical director of the Stress Reduction Clinic at the University of Massachusetts Medical Center, John KabbatZin, developed a way to make the Dharma applicable and relevant to

62  Ways of Being Western science and clinical practice through what would eventually be called mindfulness-based stress reduction (MBSR). Since that time, mindfulness-based therapies have continued to evolve, including but not limited to mindfulness-based cognitive therapy (Segal, Williams, & Teasdale, 2002), mindfulness-based relapse prevention (Bowen, Chawla, & Marlatt, 2011); mindfulness-based eating awareness training (Kristeller, Baer, & Quillian-Wolever, 2014; and mindfulness-based elder care (McBee, 2008). Of course, MBSR did not emerge from either a religious or secular vacuum. Kabat-Zinn (2013) built the MBSR program after the foundational work of early investigators such as Daniel Goleman and Herbert Benson in the 1970s who found that meditation was capable of lowering heart rate, oxygen consumption, blood pressure, and skin resistance. Meditation’s capacity for affecting physiology was summed up in what Benson called the relaxation response. The therapeutic benefits of meditation have since, by one estimate, been documented in 813 empirical studies, with half of these studies published after 1994, meaning that the rate of interest in mediation appears to be increasing in scientific circles (Ospina et al., 2007). There are at four major connections to be made between this growing body of scientific work and the ways R/S helpers have construed the manner and function of the healing presence. These include the Presence-Attunement-Resonance-Trust paradigm according to Segal’s (2017) Mindsight for Clinicians based on Buddhist psychology, the vocation of the Bodhisattva in Mahayana Buddhism, Kataphatic and Apophatic contemplation in Christian mysticism, and the notion of the Divine Dance in Trinitarian Theology. Presence-Attunement-Resonance-Trust Much of the reason why meditation is beneficial for therapists to practice is easily summed up in Daniel Siegel’s (2017) adaptation of Mindsight for Clinicians using the acronym PART (Presence-Attunement-ResonanceTrust). Presence has largely been the topic we have covered thus far. However, through the lens of meditation in particular, presence is a function of a receptive state of mind, an open posture of nonjudgmental acceptance and awareness of the client which could be categorized as a mindful state of consciousness. This posture is one of the primary outcomes of a dedicated meditation practice. Presence makes it possible for the second aspect of PART, attunement, to exist. Attunement is closely related to Daniel Goleman’s (2005) concept of emotional intelligence and is the primal foundation for empathy. Attunement is the capacity to cue into your own internal state as well as the internal world of the client. As researchers have found, adopting a practice such as Loving-Kindness Meditation (LKM) in beginning therapists can increase a sense of empathy for their clients (Leppma & Young, 2016). The third component of PART is resonance. Through presence and attunement, therapists become in sync with their clients and a deep connection is established. Of course, this does not

Ways of Being 63 mean that the therapist and the client are the same person. Instead, this is the essence of the phrase “the whole is greater than the sum of its parts” because in this moment of connection “I” becomes “we.” Through presence, attunement, and resonance, the final aspect, trust, is possible. It is here that therapeutic bonding becomes a reality. Without this essential element it is likely therapy would lose much of its power and potential to effect positive change (Norcross, 2011). PART is a parsimonious description of how the mechanics of contemplative practices develop ways of being. From this theoretical foundation it is possible to see how connections to the great ideals of compassion, love, and wisdom, in R/S traditions, find expression. The Bodhisattva and the End of Suffering Arguably a key unifying motivation for many therapists to embark upon is to create a better world through their work providing some antidote for the pain people experience. The desire to help alleviate the suffering of other people, of course, did not suddenly appear during the foundational work of Western psychologists at the turn of the twentieth century. The roots of compassion extend far back into the history of human societies. One particularly relevant example comes from the intersection of contemporary therapy and religious practice—the identity and vocation of the bodhisattva in Mahayana Buddhism (Makransky, 2012). In the Mahayana interpretation of the Buddha’s teachings, compassion took on central importance because what seemed to set the Buddha apart from his contemporary teachers was that he had not just the capacity for wisdom (the liberating insight into the impermanence of existence) but also had a unique ability to pass this teaching on so that others could also experience the liberation of awakenment. A bodhisattva then is one who aspires to follow the Buddha’s compassionate example helping others experience the cessation of suffering that comes from the perfection of wisdom. Certainly, there are prominent historical figures who could be identified as bodhisattvas, such as Martin Luther King, Jr., or Gandhi. While not reducible to exact equivalents, there are striking similarities between the bodhisattva and the modern vocation of a professional helper. For instance, some professional helpers see their role not as psychological change agents only, but social and societal as well. Building off of Bronfenbrenner’s ecological theory, the Multicultural and Social Justice Counseling Competencies (MSJCC) view the helping process holistically where systems of oppression, not individual psychological dysfunction only, are targets of change to promote a more just society and alleviate the suffering of oppression in all forms (Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2016). Or, at the very least, a therapist’s sense of calling to alleviate suffering can find a continuity and connection to the ancient vocation and the transcendent ideals of the bodhisattva.

64  Ways of Being The Wise Therapist The concept of the wise self is something we already introduced in Chapter 2, and has a rich history in R/S, from the court counselor in ancient Judaism to the Guru in ancient India. Contemplatives are often prized, and indeed admired, for their wisdom. Sage advice is sought often from figures like the Dalai Lama, Archbishop Desmond Tutu, Ken Wilber, Deepak Chopra, and Thomas Keating, among others. In turn, wisdom is something that clients depend on from their therapists to navigate the various problems they bring with them to work through. Moreover, wisdom is often associated with what we have already seen is a benefit, contemplative practice—compassion—forming two essential characteristics of a helper (Germer & Siegel, 2012). When asking what makes a wise therapist, researchers have found that there are essentially five qualities that come to the surface: intelligence, insight, a reflective attitude, concern for others, and problem-solving abilities (Siegel, 2012). These five characteristics alone can easily be practiced and developed from the lenses of conventional therapy training, However, R/S wisdom adds transcendent depth to these attributes which are often missing from Western psychological perspectives. Thus, intelligence for a therapist can include the traditional factors of fluid and crystalized intelligence, along with training in developmental psychology, diagnosis, or evidence-based practices while adding a focus on universal or timeless truths, such as hope, faith, nonviolence, love, etc. Moreover, when therapists embrace contemplative practices, they may also add to this list other qualities of wisdom that find support in the world’s wisdom traditions, that include the insight into impermanence or the mysterious flux of life, the ability to spot enslavement of desire, interdependence of self or no-self (annata), and discernment—a quality particularly prized in Western theism. Seeing and Unseeing, Knowing and Unknowing Much of the literature covering the application of meditation in therapy has originated from either Buddhist psychology or from Western adaptions of it. Though there is debate around how to categorize a closely associated practice like contemplative prayer in the context of contemporary Western science and meditation, we take the position that the two are more alike than they are different and there are significant contributions still to be made by bringing these two histories of contemplative practice into dialogue. One area that we cover here is the experience of kataphatic and apophatic contemplation, which we introduced as a way of understanding. One of the most cherished forms of kataphatic contemplation in the Christian tradition is the sixteenth-century classic The Spiritual Exercises of St. Ignatius of Loyola as well as its various offshoots and adaptations such as the Ignatian Examen. This type of

Ways of Being 65 contemplation is sometimes referred to as via positiva, in contrast with the apophatic tradition, because it stresses the immanence of God and what can be grasped through the faculties of the human mind. As we said, apophatic contemplation removes all images or words which symbolize one’s understanding or experience of God, and the transcendent, unknowable mystery of God is approached through the means of pure faith where a deeper intimacy, known as the “negation of negation,” develops as the self rests in the loving presence of God. It is the negative way that stresses the transcendence of God which cannot be grasped through reason alone but may only be known in love. Rodgerson (2012) said that apophatic and kataphatic prayer experiences help to shape and form how the therapist focuses “not only on what they attend to, but what they attend from” (p. 4). For instance, if translated in the terminology we have used thus far as ways of being, the experience of kataphatic attending stresses the manifest content of the therapeutic encounter. This would include the words clients use to describe their story, their nonverbal expression of emotions, or assessment results they or others complete as a routine process of taking a full bio-psycho-social history to locate and add context to their problem, predicament, or person. On the other hand, apophatic attending requires a deeper look beyond the manifest content of words and gestures, to the latent content, often encountered as depth of meaning. Much like Buber’s phenomenology of the ungraspable mystery of the other, apophatic attending requires a willingness to risk unknowing, allowing the client to at last reveal their deepest self. Or, as the psychoanalyst Theodore Reik (1948) would say, the most important characteristic of a therapist is the “moral courage not to understand” (as cited in Cooper-White, 2007, pp. 239–240). Not to be misunderstood as merely ignorance, rather apophatic attending brings deeper clarity. Much like Chesterson (1986) said of mysticism: The whole secret of mysticism is this: that man can understand everything by the help of what he does not understand. The morbid logician seeks to make everything lucid, and succeeds in making everything mysterious. The mystic allows one thing to be mysterious, and everything else becomes lucid. (p. 231) Apophatic attending is deeply associated with the concept of cultural humility where the client is held in such high regard that even clinical conclusions are held loosely to allow room for the mystery of the other person to gradually emerge (Hook, Davis, Owen, & DeBlaere, 2017). It is also closely associated with the Buddhist concept of emptiness (sunyata), the development of insight or wisdom. Whatever tradition may inform these two modes of being (kataphatic and apophatic) they form a

66  Ways of Being distinctly interconnected web of experience, and they are probably best viewed as feeding into and raising up the other (Rodgerson, 2012). This would be true of its therapeutic applications, as distinct modes of attending, as well. The Divine Dance Building from the Jewish perspective of encounter put forth by Martin Buber, relational encounters understood through the spiritual level of being recapitulate the ways that theologians and therapists alike talk about significant relational moments in therapy and with the divine. This being in relationship which mimics divine attributes finds particular expression in Trinitarian formulations (Rohr, 2016). The kind of hospitality which therapy holds as an ideal to offer clients as a means for transacting positive growth and development can be found in the intuitions of Trinitarian mystics. For example, the Rublev Icon, a fifteenthcentury depiction of the Trinity, serves as an iconographic illustration of the radical proposition of God as three in one as a revelation into the very nature of being, as opposed to, as Rohr quipped, an odd solution to a mathematical problem (1  +  1 + 1  =  1). A depiction of the icon can be found easily through an internet search. In the icon, three features are especially illuminating for this discussion. First, the inclusion of three persons is significant in so far as it implies diversity; the three persons are not identical. Second, the exact depiction of the persons in the icon is not as important as dynamic relationship and directionality of their positioning. As one visually follows the Father (at the top of the icon) to the Son (seated down and to the right), and finally to the Holy Spirit (across and to the left), back to the Father, there is a sense of flow among the persons that is unending. This sense of movement into and out through each person is what early Christians called perichoresis, often rendered into English as the divine dance (Cooper-White, 2007). This dynamic movement is meant to evoke an intuition into the nature of being as both unlimited outpouring (giving) and unlimited inpouring (receiving). Last, one feature is actually likely missing from the icon itself—a small mirror sitting within the midst of the persons. Rohr suggests that this feature was intended to remind the viewer that within this divine flow emerges one’s truest self. Thus, the Trinity is not some “exclusive club or divine committee of three,” rather the invitation is open for all living creatures to join at the table of communion (Cooper-White, 2007, p. 77). There are several implications for understanding how “being” itself is made tangible and translatable among persons who encounter one another in the midst of therapy based on this exegesis of the Rublev icon. First, if the nature of being itself is the vulnerability of both giving and receiving, it is no wonder that someone like Carl Rogers, who we began

Ways of Being 67 this chapter quoting, would describe one of the most vulnerable types of relationships (the therapeutic relationship) in spiritual language. While it should be acknowledged that the well-being of the client is the focus of the relationship, being with people in their most vulnerable condition requires much from the therapist, which is why self-care is invaluable and why spiritually based strategies are often recommended for therapists to remain resilient (Wicks, 2008). Next, the importance of being open to the other requires a fundamental openness to oneself, in the RogersTillich dialogue this is what was meant by their phrase listening love, which they clarified as a deep listening to the other, as well as a listening to oneself (see Rogers et al., 1989) which is the essence of agape. As Doehring (2015) and Rodgerson (2012) have argued, therapists can better attune to their deepest self, and thereby their way of being, through contemplative practices. Third, pluralism is assumed. While we spend a significant amount of time delving into the nuances of diversity in a subsequent chapter, suffice it to say here that comprehending the dynamic nature of Trinity means encountering unity in diversity (where we get the English work universe). To relate this insight back to therapy, differences between a therapist and their client can not only be respected but celebrated. When such differences do arise, the primary burden is, of course, on the therapist to prevent their biases from obstructing their connection to their client. However, this would also call for the general public to recognize that a therapist who has a different perspective may also be very helpful in illuminating a client’s cultural blind spots and conditioning. Last, out of this dynamic relational context emerges new life (hence the mirror in the Rublev Icon). The great beauty of therapy is its capacity to help people break free of old hurts, abandoning life-inhibiting and dysfunctional patterns of living, and discover or rediscover hope and joy for living. In short, therapy like the hospitality of the Trinity creates what St. Hildegaard of Bingen called fecundity, the context for which growth occurs, where deeper and more complex relationships emerge, and the healing of prior wounding may find resolution (Craine, 1997). This is not far off from Pamela Cooper-White’s (2002) interpretation that the Trinity is an insight into the nature of being as inclusivity, community, and freedom, all of which are values embraced by the helping fields.

Concluding Thoughts and Invitation for Reflection Ways of being take on unique shades and layers of meaning when they are viewed in the context of R/S. They have the potency to call helpers toward the highest ideals of love, compassion, and humility amid their most potent encounters with other human beings. The dispositions we have discussed in this chapter require intentional engagement and exercising, or else they remain ideas only. Without experiencing these concepts, they remain only words on the pages of a book. It is worth taking

68  Ways of Being some time, then, to read through the questions for reflection in Box 3.1 and to find ways of applying these concepts to your own way of being.

Box 3.1  Ways of Being Reflection • In what ways have you been formed by religion or spirituality in your family, community, culture, upbringing, or ancestry? How have these “fiduciary networks” as Polanyi called them, created a tactical framework for your way of being? • In what ways have you experienced transcendence and imminence? Can you describe them to yourself or to someone else who may also understand what they are like? • What has helped you connect with clients at significant depth? What gets in the way? • How would others describe your way of being? • Have you ever experienced a contemplative practice firsthand? If you haven’t, what would persuade you to try? Would you consider taking one on for a time and seeing how it may work for you? • Think back to the last time you experienced a powerful session with a client? What was going on that left such an indelible mark in your memory? How did you get to that place? • In what ways are you living up to your highest aspirations of love, compassion, humility, and wisdom in your clinical practice? What barriers need removing that block you from them? • How are you fostering virtues of presence through daily exercise? • When is the last time you have been really vulnerable with another person? What about with the God of your understanding? • What spiritual practices are you drawn to? How do they help you come into contact with the fullness of existence?

References Barbezat, D., & Bush, M. (2014). Contemplative practices in higher education: Powerful methods to transform teaching and learning. San Francisco, CA: Jossey-Bass. Bowen, S., Chawla, N., & Marlatt, G. A. (2011). Mindfulness-based relapse prevention for addictive behaviors: A clinician’s guide. New York, NY: Guilford Press. Buber, M. (1970). I and thou. New York, NY: Charles Scribner’s Sons. Burghardt, W. J. (1989). Contemplation: A long loving look at the real. Church, 5, 14–18.

Ways of Being 69 Chesterston, G. K. (1986). The collected works of G. K. Chesterton (Volume 1: Heretics, Orthodoxy, The Blatchford Lectures). San Francisco, CA: Ignatius Press. Cheston, S. E. (2000). A new paradigm for teaching counseling theory and practice. Counselor Education and Supervision, 39(4), 254–269. Cooper, M. (2017). Meeting at relational depth. Therapy Today, 28(9), 28–32. Cooper-White, P. (2002). Shared wisdom: Use of the self in pastoral care and counseling. Minneapolis, MN: Fortress Press. Cooper-White, P. (2007). Many voices: Pastoral psychotherapy in relational and theological perspective. Minneapolis, MN: Fortress Press. Craine, R. (1997). Hildegard: Prophet of the cosmic Christ. New York, NY: Crossroad Publishing. Crossley, N. (1996). Intersubjectivity: The fabric of social becoming. London, UK: Sage. Davis, J. (2000). Ritual as therapy, therapy as ritual. Feminism, Community, and Communication, 11(4), 115–130. Germer, C. K., & Siegel, R. D. (Eds.). (2012). Wisdom and compassion in psychotherapy: Deepening mindfulness in clinical practice. New York, NY: The Guilford Press. Goleman, D. (2005). Emotional intelligence. New York, NY: Bantam. Griffith, J., & Griffith, M. (2012). Encountering the sacred in psychotherapy: How to talk with people about their spiritual lives. New York: Guilford Publications. Hook, J., Davis, D., Owen, J., & DeBlaere, C. (2017). Cultural humility: Engaging diverse identities in therapy. Washington, DC: American Psychological Association. James, W. (1902/2003). The varieties of religious experience. New York, NY: Penguin Putman. Kabat-Zinn, J. (2013). Full catastrophe living. New York, NY: Bantam. Kagan, N. (1980). Influencing human interaction—Eighteen years with IPR. In A. K. Hess (Ed.), Psychotherapy supervision: Theory, research, and practice (pp. 262–283). New York, NY: Wiley Blackwell. Kristeller, J. L., Baer, R. A., & Quillian-Wolever, R. (2014). Mindfulness-based eating awareness training: Treatment of overeating and obesity. In R. A. Baer (Ed.), Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications (2nd ed.) (pp. 119–139). San Diego, CA: Elsevier Academic Press. http://dx.doi.org/10.1016/B978-012088519-0/50005-8 Lazarus, A. A. (1981). The practice of multimodal therapy. New York, NY: McGraw-Hill. Leppma, M., & Young, M. (2016). Loving-kindness meditation and empathy: A wellness group intervention for counseling students. Journal of Counseling & Development, 94(3), 297–305. doi:10.1002/jcad.12086 Makransky, J. (2012). Compassion in Buddhist psychology. In C. K. Germer & R. D. Siegel (Eds.), Wisdom and compassion in psychotherapy: Deepening meaningfulness in clinical practice (pp. 61–74). New York, NY: Guilford Press. Mearns, D., & Cooper, M. (2005). Working at relational depth in counselling and psychotherapy. London: Sage.

70  Ways of Being McBee, L. (2008). Mindfulness-based elder care: A CAM model for frail elders and their caregivers. New York, NY, US: Springer Mitchell, M. (2006). Michael Polanyi, Alasdair Macintyre, and the role of tradition. Humanitas, 19(1–2), 97–125. Neale, M. (2017). Buddhist origins of mindfulness meditation. In J. Loizzo, M. Neale, & E. J. Wolf (Eds.), Advances in contemplative psychotherapy: Accelerating healing and transformation (pp. 17–34). New York, NY: Routledge. Norcross, J. (2011). Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.). New York: Oxford University Press. O’Grady, K. A., White, K., Schreiber-Pan, H. (2015). Cross-cultural counseling: The importance of encountering the liminal space. In E. Maynard & J. Snodgrass (Eds.), Understanding pastoral counseling (pp. 161–179). New York, NY: Springer Publishing Company. Ogden, T. H. (2004). The analytic third: Implications for psychoanalytic theory and technique. The Psychoanalytic Quarterly, 73(1), 167–195. Ospina, M. B., Bond, K., Karkhaneh, M., Tjosvold, L., Vandermeer, B., Liang, Y., . . . Klassen, T. P. (2007). Meditation practices for health: State of the research (Evidence Report/Technology Assessment No. 155, AHRQ Publication No. 07-E010). Rockville, MD: Agency for Healthcare Research and Quality. Otto, R. (1923). The idea of holy (2nd ed.). Oxford University Press. Pargament, K. I., Lomax, J. W., McGee, J. S., & Fang, Q. (2014). Sacred moments in psychotherapy from the perspectives of mental health providers and clients: Prevalence, predictors, and consequences. Spirituality in Clinical Practice, 1(4), 248–262. Polanyi, M. (1962). Personal knowledge: Toward a post-critical philosophy. Chicago, IL: University of Chicago Press. Polanyi, M. (1966). The tacit dimension. Garden City, NY: Anchor Books. Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (2007). Changing for good. New York: William Morrow. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48. http://dx.doi.org/10.1002/jmcd.12035 Reik, T. (1948). Listening with the third ear: The inner experience of a psychoanalyst. New York: Farrar, Straus. Rodgerson, T. E. (2012). Apophatic attending: An essential for pastoral diagnosis. Journal of Pastoral Care and Counseling, 66(1), 1–8. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103. https:// doi-org.stetson.idm.oclc.org/10.1037/h0045357 Rogers, C. R. (1980). A way of being. New York, NY: Houghton Mifflin Company. Rogers, C. R. (1986). Client-centered therapy. In I. L. Kutash & A. Wolf (Eds.), Psychotherapist’s casebook: Theory and technique in the practice of modern psychotherapy (pp. 197–208). San Francisco: Jossey-Bass Publishers. Rogers, C. R., Kirschenbaum, H., & Henderson, V. L. (1989). Carl Rogers’ dialogues: Conversations with Martin Buber, Paul Tillich, B.F. Skinner, Gregory Bateson, Michael Polanyi, Rollo May, and others. Boston, MA: Houghton Mifflin.

Ways of Being 71 Rohr, R. (1999/2003). Everything belongs: The gift of contemplative prayer. New York, NY: The Crossroad Publishing Company. Rohr, R. (2016). The divine dance: The trinity and your transformation. New Kensington, PA: Whitaker House. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY, US: Guilford Press. Siegel, R. S. (2012). The wise psychotherapist. In C. K. Germer & R. D. Siegel (Eds.), Wisdom and compassion in psychotherapy: Deepening mindfulness in clinical practice (pp. 138–153). New York, NY: The Guilford Press. Siegel, D. J. (2017). Interpersonal connection, compassion, and well-being: The science and art of healing relationships. In J. Loizzo, M. Neale, & E. J. Wolf (Eds.), Advances in contemplative psychotherapy: Accelerating healing and transformation (pp. 118–130). New York, NY: Routledge. Stoltenberg, C., & McNeill, B. (2010). IDM supervision: An integrative developmental model for supervising counselors and therapists (3rd ed.). New York, NY: Brunner-Routledge. Turner, V. (1969/2017). The ritual process: Structure and antistructure. New York, NY: Routledge Press. Wicks, R. J. (2008). The resilient clinician. Oxford: Oxford University Press. Wiggins, S., Elliot, R., & Cooper, M. (2012). The prevalence and characteristics of relational depth events in psychotherapy. Psychotherapy Research, 22(2), 139–158. Yalom, I. (1980). Existential psychotherapy. New York: Basic Books. Young, M. (2015). Learning the art of helping: Building blocks and techniques. Prentice Hall. Young, M. E. (2017). Learning the art of helping: Building blocks and techniques. New York, NY: Pearson.

4 Ways of Intervening

In the ways model (Cheston, 2000), ways of intervening are “the work of therapy . . . the means by which a counselor interrupts the client’s cycle of dysfunction and allows for the processing of healthier alternatives of thinking, feeling, and behaving” (p. 257). While ways of intervening vary by theoretical orientation, they are always an explicit interruption of dysfunctional client dynamics. When the content or object of an intervention intersects with the shared therapist-client construction of R/S, integration takes place. Aten, McMinn, and Worthington (2011) identified several common interventions that potentially meet this definition: prayer, forgiveness, meditation, mindfulness, yoga, scripture reading, and journaling. Additional candidates might include activities such as ritual, visualizing deity, compassion exercises, gratitude, and the Twelve Steps. Many researchers emphasize that there needs to be work to delineate the “spiritual” part of spiritual interventions as opposed to that which could be described more parsimoniously through existing psychological constructs. While this work has undoubtedly helped “legitimize” psychospiritual approaches as an important area of scholarship and practice, making this distinction with clients is not overly helpful. As the lived religion approach suggests, the breadth of what clients experience as R/Sintegrated intervention can vary from person to person. While it may be possible to demonstrate such fine distinctions in research, clients rarely bring such isolated dimensions into therapy. More often, clinicians are asked to explore psychospiritual themes in complex, existing R/S frameworks. Forcing clients to parse out what parts of their experiences match empirical constructs of R/S is not a productive use of the relationship. Moreover, the lived religion approach is consistent with many of the most popular R/S interventions. For instance, a secular client may see a therapist’s recommendation of daily gratitude practices as not particularly spiritual, and certainly not a transgression of a cultural boundary. On the other hand, a Roman Catholic client influenced by Ignatian spirituality may want to integrate this practice into an established practice of Daily Examen (Ignatius Loyola, 1964). Comparing these two clients

Ways of Intervening 73 shows how many R/S interventions are protean, fitting into clients’ worldviews in ways with very different implications. For the first client, the gratitude exercises may promote positive mood and even create habits that another client would consider spiritual. For the second client, the same therapeutic exercise becomes interwoven with a tool for spiritual development. The implications can run in the opposite direction as well. Consider how therapists with a conservative Christian background have construed mindfulness practice (Jackson, 2015): some see it as a kind of “brain technology” that can be used without any issue, whereas others see it as an unethical intrusion of another religion into their care. For this reason, the worldview and cultural identity of the client in part determine what counts as R/S integration. In addition, affirming a client’s R/S identity can be essential to the development of the therapeutic relationship, with clients ranging from Pentecostal Christians to Pagans reporting an expectation of not being taken seriously or of stigma (Harris, Randolph, & Gordon, 2016). This ambiguity means that R/S interventions in psychotherapy not only have to meet the burden of empirically informed practice, but they also involve the complicated process of broaching (Day-Vines, 2007), in which counselor and client mutually navigate bringing up sensitive issues. While this complexity is probably a disincentive from attempting to use R/S interventions in psychotherapy (and the evidence suggests that many practitioners avoid it for this reason), there is also substantial evidence that these interventions are powerful and may even be essential in some cases to the therapeutic relationship. Spirituality and religion have been empirically linked to several positive mental health outcomes (Bonelli & Koenig, 2013; Park & Slattery, 2013), most strongly in reducing substance abuse, depression, and suicide, and in promoting subjective well-being. Positive results have also been observed in the treatment of anxiety disorders including PTSD, and dementia, and in stress reduction. Moreover, randomized controlled trials of spiritually oriented interventions have supported the use of forgiveness (Toussaint & Webb, 2005; Wade, Hoyt, Kidwell, & Worthington, 2014), gratitude (Emmons & Stern, 2013), and mindfulness (Brown, Marquis, & Guiffrida, 2013) in treatment. In addition to their efficacy, spiritual interventions are often culturally competent, tapping into indigenous coping strategies and resources. For this reason, this chapter develops a broad approach for considering the ways in which spiritual and religious content is addressed through therapeutic interventions. While R/S interventions have received a lot of attention in scholarship over the past decade, few authors provide a framework for conceptualizing and evaluating these interventions. We have decided to stay away from an indexed presentation of one R/S after

74  Ways of Intervening another. Instead, from the many ways to categorize R/S interventions, we find that four key dimensions emerge: 1. The level of the client’s ecological system (individual, family, organizational, etc.); 2. The level of critical reflection and transformation of the client’s existing R/S framework; 3. The phenomenological level of experience addressed (conscious, unconscious, or transpersonal); and 4. The degree to which the intervention is embedded in an R/S tradition.

Interventions and the Client Ecosystem The first dimension to consider in integrating R/S into therapeutic interventions is the target of that intervention in the client’s ecosystem. Human behavior is not only personal, but also contextual and interactional (Cook, 2012), involving complex relationships among multiple systemic levels. R/S interventions can interface with one or more of these levels in promoting client development and well-being. For instance, there is considerable evidence that involvement in a religious congregation can be beneficial for mental health (Ellison, Boardman, Williams, & Jackson, 2001), including (but not limited to) the social support and frames for meaning-making that congregations provide. Suppose a client reports affiliation with a congregation as part of their R/S history but has recently strained ties with fellow parishioners because of their symptoms of depression. Many therapists would consider ways in which to help the client sort out positive from negative dynamics in these relationships and might potentially recommend increased engagement with the positive aspects of congregational life as a way to promote activation and social support for a client. In extreme cases, a clinician may even help the client consider the implications of finding a different R/S community if the current one proves abusive. This sort of intervention might not register as an R/S one to many clinicians, but in increasing the client’s contact with R/S rituals, coping strategies, and support, it clearly meets the criteria we have established, and requires some thought to how the R/S dynamics of that level of engagement with the client’s ecosystem can be transformative beyond simply providing a support network. The developmental theorist Urie Bronfenbrenner (1979) provided a useful theoretical model for conceptualizing the different levels of the client’s ecosystem: The microsystem is the closest level of the ecosystem and consists of contexts in which there is face to face contact with the client—family, coworkers, small groups, etc. The mesosystem consists of relationships among microsystems: home and school, work and family, church and civic organizations, etc. The exosystem consists of those larger systems in which a person does not participate, but whose decisions

Ways of Intervening 75 influence a person: religious bodies, governments, corporations, health care systems, the media, zoning boards, etc. Finally, the macrosystem is the most distant influence on the client, consisting of the structures and cultural apparatus of a society: laws, language, economies, stereotypes, roles, ideals, climate, etc. Many of these levels can be salient to both case conceptualization and intervention. For instance, interventions targeting the micro- or mesosystem levels of a client’s R/S can be especially indicated for certain cultures and religious communities. Many therapists are aware of the importance of church to many African Americans. As the only place to find mutual aid and support in the pre-civil rights era, churches became major centers for education, organization, and leadership in the African American community (Cnaan & Boddie, 2006). Another group for whom congregational links to well-being have been well documented is the Latin population, for whom religion provides a major source of identity, creating social cohesiveness and social organization from communities with widely varied national and cultural roots (Cnaan & Boddie, 2006). Finally, authors have pointed out the importance of congregations in the lives of immigrant groups (Ebaugh & Chafetz, 2000). Counselors working with clients from these backgrounds are unlikely to be able to be effective without interfacing with this level of the ecosystem in some way. It is also worth pointing out that the impact of R/S organizations on client lives can be positive, negative, or some combination, which means that therapists need skill in discerning and addressing these relational dynamics. While the role of religious communities in the lives of clients from these different cultural groups is well appreciated, there are other, less known situations in which counseling interventions can fruitfully involve R/S groups—either formal or informal. For instance, Paganism has been a refuge for many individuals from sexual minority groups (e.g., LGBTQI, BDSM/kink; Kraemer, 2012) that allows them to find affirmation in conjunction with R/S resources. While Pagan groups tend to be led by lay practitioners (Reece, 2014), there are widespread cultural and personal connections among this community that could be addressed in counseling. Moreover, Paganism is a faith group that is especially interested in integrating spirituality with holistic health and wellness (Heelas, 2008). While it is possible to consider intervening in multiple levels of a client’s ecosystem, this is not always beneficial or feasible. One criterion for considering ecological R/S interventions is that of parsimony (Conyne & Cook, 2004), the smallest change that is likely to help the client without introducing unintended consequences. Moreover, beyond parsimony, working with faith-based communities requires therapists to develop specific competencies (Stewart-Sicking & Mutai, 2012): commonality in mission, respect for value and mission differences, and building on existing assets.

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Level of Critical Reflection Wherever they are deployed across different levels of the client’s ecosystem, R/S interventions take one of two primary forms: conservational or transformational. These categories come from Pargament’s (1994, inter alia) model of R/S coping. In it, Pargament assumes that R/S coping is a form of seeking significance through employing personally compelling resources from one’s culture. These resources can target the pathways to significance or the destinations that one deems significant. The process of coping can either conserve one’s framework for significance or transform it. It is possible to detect when one is venturing out from conservation toward transformation by considering the level of meaning being negotiated in any therapeutic intervention. Jennings (1990) suggested there are three possible levels. The first is the kind of meaning a therapist might use in conservational interventions, what Jennings called first order religious language. It involves meaning which is mostly embedded, nonconscious, and pre-critical. It is the set of language symbols which are absorbed through one’s R/S community, education, upbringing, and acculturation. While not reflective, this language is perfectly suitable for many experiences which people go through across a life span, but it does form the windows out from which people see their worlds. Religious people may, for instance, describe their abuse history as a “living hell” or that “God was punishing me” or a nonreligious person may describe their future goals in connection with the “universe’s plans” or “if it is meant to be it will be.” Problems can occur when the R/S language is no longer potent enough to address one’s mental and emotional turmoil. When the focus of therapeutic interventions has exhausted the reservoirs of first order language, it can turn a corner into transformational coping, what Jennings called second order religious language. As an illustration, one of us once worked with a man well into his retirement years who was deeply distraught after learning that he had been celebrating Christmas as a pagan ritual. He believed he was failing God in an almost adulterous manner by engaging in an act ritualized by pagan deities. After inquiring what he had done that he felt was so wrong he said, “I have a Christmas tree.” When asked how he came to this understanding, he said, “I read it on the internet.” Therapeutic interventions at this level involve critical reflection on the origin, tradition, doctrine, education, or life experiences that formed the embedded layer of first order religious language. These reflections involve deliberation, time set aside for critical reflection, which may take place in the context of therapy or outside it at higher levels of the client’s ecosystem (e.g., clergy, formal religious education, fellow devotees). For this man, learning more about his Christian heritage helped to dispel the notion that he was cheating on God by decorating a Christmas tree, thereby helping to alleviate a spiritual crisis.

Ways of Intervening 77 A further layer of transformation can occur through third order religious language. This transformation reflects critically not only on the potential meaning of R/S language, but also on the cultural dynamics through which this meaning was constructed. This type of language is more common when clients significantly invest in their tradition by pursing formal education or training. These three levels can be used as a means of locating where a therapeutic dialogue is leading, either into conservation or transformation, and as a means of accountability for when a therapist may be overstretching their role and venturing too far into assuming the role of a client’s R/S authority. Conservation Conservational R/S coping utilizes existing R/S frameworks and practices as ways to assimilate experiences into a sacred framework. While Pargament’s research has tended to focus on theistic groups, he has identified several common patterns (Pargament, 2011): reframing a stressor through R/S lenses, seeking support from the sacred through practices such as prayer or scripture reading, seeking support from clergy or other believers, seeking connection with sacred forces, providing spiritual support to others, partnering with the divine in problem-solving, and spiritual purification. These activities engage existing R/S resources in service of psychological goals such as coping or development and do not change the content of those resources. Conservational R/S interventions are the least problematic for therapists to engage in that they come from the client’s worldview and keep it intact. Using Jenning’s (1990) framework, these are all interventions which exist within first order religious language and are not intended to challenge the client to weigh the merits of their existing R/S resources. Moreover, they don’t require the clinician to be personally competent in the intervention or to critique it. For instance, a therapist might ask a client struggling with thoughts of worthlessness for a scripture verse she would share with someone in a similar situation and then use that verse for reframing. The same client might be encouraged to end each day with the practice of listing five events for which she is thankful to God. Many conservational R/S interventions such as these are already part of counselors’ repertoire. While every therapeutic intervention requires prudence, many therapists would have no problem in calling upon them. In these ways, these kinds of interventions are similar to other culturally sensitive interventions that are widely employed. They are potentially more powerful precisely because they are indigenous to the client’s ecosystem. However, R/S interventions are not exactly the same as other culturally derived interventions. As Tillich (2009) pointed out, R/S matters are not one among many; rather they are matters of ultimate concern and therefore can inhabit a central and organizing role for the client’s motivations,

78  Ways of Intervening beliefs, and emotional lives. In engaging clients’ constructions of R/S, the therapist is inviting powerful and precious entities into the therapeutic relationship, and therefore must be especially prudent in moving forward. The primary risk of conservational R/S interventions is one of unintended consequences, because no intervention is entirely conservational. Consider the client just mentioned, overwhelmed with thoughts of worthlessness, who has now latched onto a favorite scripture verse for comfort and reframing the situation: “I praise you because I am fearfully and wonderfully made; your works are wonderful, I know that full well” (Ps 139:14, NIV). Throughout the week between therapy sessions, she repeats this verse to herself as a reminder that she is a wonderful creation of God of intrinsic worth. She might approach the verse almost contemplatively over time, emphasizing different words over time: “praise,” “wonderfully,” “Your works,” “I know.” But over time, she might get diminishing returns on how comforting this thought is, and as it becomes more and more associated with times of sadness, the words might remain, but now come across as ironic or impotent, or she might question them with other R/S thoughts: “a sinner since my mother’s womb” (Ps 51:5, NRSV). Traditions of spiritual practice have long known that attachment to the content or effect of a specific exercise inevitably leads to spiritual struggles (e.g., John of the Cross, 1979). Indeed, therapists know that this is the case with interventions more generally. Therefore, conservational interventions are unlikely to be sufficient in long-term work with clients. We should expect clients to grow spiritually just as they develop psychologically. When people feel the power of their existing R/S frameworks and processes, this would usher in the opportunity to do what Jennings (1990) described as second order religious language or what Pargament (2011) called transformational coping. Transformation Transformational R/S coping occurs when the client’s experience and understanding of spirituality is being stretched. Old solutions, relationships, and practices no longer work, and the client enters into a time of spiritual struggles, evocatively known to Christian spirituality as the Dark Night, related to the discussion of suffering we entered in Chapter 2. These circumstances provide more of a challenge for the therapist and can be an area in which specialization or referral is needed, since the client’s construction of spirituality must change, and this can be a frightening or unwanted possibility for the client. Jennings (1990) as well as Doering (2009) acknowledged that second order religious language requires a deeper engagement with a client’s tradition, and oftentimes therapists lack the experience, education, or authoritative role to handle transformational moments. In those cases, networking into the

Ways of Intervening 79 higher levels of the client’s ecosystem can be invaluable for education and guidance. In Pargament’s (2011) model, transformational R/S coping arises from two types of problems. There are problems of spiritual pathways, which can be either too narrow, too shallow, too inflexible, or a poor fit of person and environment. For instance, a client might be inexperienced in the practice of prayer, cling too tightly to a specific religious observance, or even be in abusive religious relationships. Problems of spiritual destinations can result from having too limited an image of the divine, making some finite object into an idol, or experiencing assaults from negative spiritual forces. Spiritual struggles force a client into deciding whether to come to a new understanding of the sacred or to remain stuck and clinging to inadequate ones (Orton & O’Grady, 2016). Transformational R/S interventions are called for when therapists judge that clients’ R/S constructions are a source of their distress. In cases of transformational interventions, R/S language is used in a new way and corresponds to second order or third order religious language. Whereas conservational interventions draw uncritically on clients’ embedded language and practices, transformational interventions engage in critical thinking about these constructions. This competence is the essence of theological reflection, which is the central feature of the discipline of pastoral counseling. Pastoral counselors have rightly criticized some approaches to R/S in treatment as theologically naive (Doehring, 2009), because an inability to engage in critical reflection on R/S (characteristic of disciplines such as theology) makes it likely that therapists will see others’ faith through the lens of their own or lack thereof. For this reason, it is important that therapists who routinely encounter situations in which transformational religious interventions are called upon have a basic training in critical reflection on their own and their clients’ traditions (Stewart-Sicking, 2008). We discuss these competencies in more detail in Chapter 9. A more difficult problem comes to light when we consider that, for many clients and therapists, what counts as their tradition is often underdeveloped, multiple, or non-hierarchical. For clients unaffiliated with any religious group, where should the resources for transformation come from when they are experiencing spiritual struggles? If they find depth in more than one tradition, which does the therapist utilize? If the client’s faith tradition explicitly eschews formal dogma and clerical structures, who can provide consultative guidance to the therapist on distinguishing healthy from unhealthy R/S patterns? In past generations, many clinicians have simply used this messiness to argue that the solution is to treat R/S itself as the problem, and therefore adopt an entirely secular approach. If we wish to affirm the value of clients’ R/S journeys, these questions, which we explore in Chapter 7, call for an approach that can be both critical and pluralistic.

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Level of Consciousness In the words of the philosopher George Santayana (as quoted in Geertz, 2017), “The vistas [that a religion] opens and the mysteries it propounds are another world to live in.” When R/S is evoked in therapy, it opens up additional ways of living in the world, a phenomenology distinct from that of the default mode of engaging of everyday life (Schutz, 1967). Writings about R/S in counseling have recognized this difference, and in them, we can see three primary modes of engaging R/S. Engaging from Above, Below, and Beyond Above The first type of intervention utilizes conscious thought and volition to change problematic beliefs and make considered decisions. In neuropsychological terms, these interventions are described as top-down (e.g., van der Kolk, 2015) or secondary regulation (Hill, 2015) of affect through the slow-working system of mentalization (Allen, Fonegy, & Bateman, 2008) that uses left-brained functions such as deliberation and language. These interventions are experienced phenomenologically as part of our everyday intentional ways of interacting with the world, and they are widely utilized, while conceived of in slightly different ways across theories, for example, insight, reframing, cognitive restructuring, planning, etc. Considering these interventions from an explicitly spiritual framework, transpersonal therapies have spoken of these interventions as egoic (Washburn, 1988), since they engage a conscious (and for some traditions ultimately illusory) sense of self. To integrate R/S into psychotherapy, it is not necessary to accept any particular metaphysical framework for interventions from above so much as it is necessary to recognize that they are experienced in a distinct way within the client’s already existing framework. R/S interventions from above are well established in the literature, and they constitute the bulk of current practice. For instance, some of the earliest uses of R/S interventions adapted CBT to address R/S content (Propst et al., 1992). Therapists would walk clients through the implications of their R/S beliefs, and through Socratic questioning, help them develop more functional replacements and draw upon content from their R/S systems to help dispute and reinforce beliefs. Psychodynamic approaches also have a long-standing history of engaging interventions from above in arenas such as processing God-image (Rizzuto, 1979) or identifying the use of R/S as a defense mechanism, such as in spiritual bypass (Masters, 2010; Welwood, 1984; Cashwell, Myers, & Shurts, 2004), in which clients avoid difficult psychological material or spiritualize their problems to avoid difficult work (Fox, Cashwell, & Picciotto,

Ways of Intervening 81 2017). In addition, many forms of conservational and transformational religious coping listed by Pargament (2011) also fit into this category, such as benevolent spiritual reappraisals, collaborative spiritual coping, and coming to new understandings of the sacred. Below A second category of intervention engages R/S through pre-verbal, experiential reality. In neuropsychological terms, these interventions are described as bottom-up (e.g., van der Kolk, 2015) or primary regulation of affect (Hill, 2015) through the fast, unconscious, non-linguistic, rightbrained functions that relate to attachment and the limbic system. Phenomenologically, these interventions are experienced primarily through emotion and while a large part of our everyday world, they are not something we regularly notice. These interventions too have a long pedigree in counseling theory as ways to focus on relationships or emotions. For instance, Rogers’ (2012) conditions of empathy, congruence, and unconditional positive regard can be thought of in these terms, as can the mirroring and idealizing practice of self-psychology (Kohut, 2011) or attention to enactments in relational psychoanalysis (Cooper-White, 2004). Emotion-focused therapy (Greenberg, 2011) also utilizes interventions from below in emphasizing awareness, acceptance, and corrective experiences of emotion. And behavioral interventions, such as relaxation exercises or graded exposure, or experiential intervention like those espoused in psychodrama, also engage these mechanisms. When conceptualized in R/S terms, interventions from below have tended to be seen as pre-egoic (Washburn, 1988), engaging the part of the psyche that predates language and a solid sense of self. It also is associated with heart practices (Cortright, 1997) that attempt to facilitate healing experiences of relationships with deity or nature. While not as numerous as interventions from above, there are many examples of interventions from below that integrate R/S elements. For instance, the experiential focusing method (Hinterkopf, 1994) has clients attend to subtle feelings that emerge before the body-mind-spirit split. In articulating this felt sense, clients can come to a transcendent experience drawing beyond the self on healing resources. Inner healing prayer, where a client reprocesses trauma while inviting the peaceful presence of their higher power into each scene, would be another example (Tan, 1996). Certain forms of mindfulness or contemplative exercises can be seen in this form as well—though as we discuss subsequently, they also open a portal to transpersonal experiences. In Pargament’s (2011) treatment of R/S interventions, we see this form in activities such as seeking connection with transcendent, letting go, and fostering new relationships with the sacred.

82  Ways of Intervening Beyond The final mode of engaging R/S in counseling interventions transcends the self. These interventions are experienced not as everyday consciousness, but as encounters with depth, the numinous, or a perspective beyond dualism. While these interventions might invoke conscious or personal unconscious processes, they are not reducible to these aspects. They engage altered states of consciousness, ritual, or archetypal experiences and are trans-egoic (Washburn, 1988). It is worth noting also that while we have treated these three modes of engagement as if they were separate, they are interwoven into the stream of consciousness, all there to be the object of experience or intention. In the case of interventions from beyond, these properties become especially evident. For instance, consider how repeated, slow reflection on a sacred text (from above) might lead to a unitive contemplative state (from beyond) that brings us to a way of experiencing the world beyond our daily consciousnesses. Interventions from beyond have traditionally been the realm of asceticism in religious traditions, and attention to them in psychology has mainly been in transpersonal psychology, rooted in the work of Jung. If interventions from above are focused on the mind and those from below are focused on the psyche, these are focused on the soul. In engaging what Jung (1991) conceived of as the collective unconscious, these interventions draw upon a unique reservoir of psychic integration, which Jung (1957) referred to as the transcendent function. It is important to realize that while beyond language, these interventions are not mere regressions to a pre-linguistic state (something Wilber, 1982, calls the “pre/ trans-fallacy”). Jung’s work on archetypes (2014) provided one of the first modern approaches to integrating R/S into interventions from beyond. Jung theorized that engaging archetypes such as the self, shadow, animus, and anima, analysis could fulfill the role of ushering individuals into the presence of mystery that was once the function of religion, which had lost its credibility (Jung, 1928). Transpersonal psychology built upon Jung through approaches such as psychosynthesis (Assagioli, 1965) and integral psychology (Wilber, 2000). More broadly, the increasing interest in entheogens (Richards, 2009), meditation (Sedlmeier et al., 2012), and contemplative Christian practices (Gutierrez, Fox, & Wood, 2015) in psychotherapy shows that these powerful interventions can be attractive to a wider range of theoretical orientations. Ritual forms a special and widely utilized approach to integrating R/S into psychotherapy from beyond (see, e.g., Cole, 2003). As we saw in ways of being, ritual can be a mode of being, and the ritual process originally taken shape in the world’s religious traditions can be recapitulated in therapy. However, like religion and spirituality, “ritual” is a slippery term that includes many possible activities and many purposes,

Ways of Intervening 83 characterized by formalism, traditionalism, disciplined invariance, rulegovernance, sacral symbolism, and performance (Bell, 1997, p. 138). While uniquely powerful in promoting change, ritual also brings in the complexities of who has the right to administer them and where they can be done. There are six broad categories of ritual (Bell, 1997): rites of passage, calendrical/commemorative rites, rites of exchange and communion, rites of affliction, festive rites, and political rituals. Of these, three are especially pertinent to integrating R/S into psychotherapy. Rites of passage can mark a transition from one stage of life to the next through invoking the sacred. Therapists can call upon the experience of these rituals in clients’ lives as a way to re-narrate and establish new meaning through major life transitions such as birth of new life, death of a loved one, reaching adulthood, or making vocational changes. Rites of exchange and communion coordinate human offerings to the divine with divine gifts and presence. Clients might make a sacrifice as a sign of thanksgiving or partake in the Eucharist as a way of coming into contact with God. Rites of affliction seek to correct a spiritual situation that has become disordered. Clients might make use of these rituals as a way to call upon divine power to overcome tragedy (e.g., through the Christian rite of laying on of hands and anointing) or to purify themselves from ritual uncleanliness (as in the Jewish practice of using a mikvah for spiritual bathing). While interventions from beyond are especially powerful, they also raise difficult ethical issues, which we discuss later. Namely, they beg questions such as who has the authority to recommend or practice a ritual or what the responsibility of a therapist is for spiritual crisis or growth that comes from transpersonal encounters. They also raise the question on when it is prudent to choose them. PARSIMONY

As is the case with choosing the level of an ecological R/S intervention, prudence and parsimony guide which level of R/S intervention is chosen for any given client situation. Interventions from above are least likely to raise difficult questions of ethics and also require a lower level of expertise. They seem appropriate when the goal of the intervention is that the client have a new understanding of the situation. However, there are times, such as in cases of trauma or personality disorders, in which these interventions are simply insufficient. Sometimes clients need new experiences of R/S, and in these situations, interventions from below make sense. Finally, as clients approach situations of great distress or potential growth, they may require the new perspective that can only be achieved through interventions from beyond. All of these modes of engagement seem appropriate for psychotherapy, but to have this fuller palette, careful reflection on ethics and supervision become necessary.

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Embedded or Disembedded A final dimension to consider in utilizing R/S interventions in psychotherapy is whether these interventions are presented in secular terms or in the context of the traditions from which they are drawn. Some authors suggest using practices in their indigenous forms with clients from those traditions (e.g., Worthington & Aten, 2009) as these will be powerful and foster the therapeutic relationship through cultural competence. However, there is also a strong movement in fields such as positive psychology to find commonalities in practice across traditions and to improve these practices through the use of scientific method (e.g., Seligman, Steen, Park, & Peterson, 2005). The choice of whether to present an intervention within the context of a tradition is therefore not one for which clinicians have a strong consensus. Embedded Interventions The argument for embedding R/S interventions in the traditions in which they are found is that this practice enhances both cultural competence and informed consent. Like culturally embedded interventions more generally (Hall, Ibaraki, Huang, Marti, & Stice, 2016), R/S interventions embedded in a tradition that the client sees as authoritative can strengthen the therapeutic relationship and also be easier for the client to utilize in daily life by not setting apart “therapy” language as a totally separate way of encountering the world. Similar to the research on culturally adapted interventions, research on R/S accommodative interventions is growing steadily and has demonstrated their efficacy. In one meta-analysis, randomized controlled trials of R/S interventions across 97 studies found that accommodative therapies can produce large effect size differences on psychological and spiritual outcomes compared with no treatment control groups, small-medium effect sizes when compared to secular therapies, and comparable outcomes to secular therapies with the same underlying theoretical orientations when it comes to psychological outcomes and superior spiritual outcomes with small-medium effects (Captari et al., 2018). Taken together, the evidence is substantially in favor of including R/S intervention in the general practice of therapy. The evidence is so strong in fact that, much like other culturally accommodative therapies, “To ignore religion as a cultural issue may not only be unethical, but also lead to malpractice” (Plante, 2014, p. 289). We revisit these issues later in Chapter 8 where we discuss how to engage R/S research. Interventions that are construed as R/S also have the power to shape many areas of a client’s life. The wisdom traditions in which these interventions have been developed have optimized them for this purpose, and also recognized the pitfalls of their use. In seeing this context, clients are offered the possibility of consenting to encountering these traditions

Ways of Intervening 85 (Stewart-Sicking, 2008) and making judgments of their own about how compatible these are with their own worldviews and practices. The risk of this strategy is that an intervention such as mindfulness practices, which has well-documented therapeutic benefits (Brown et al., 2013), might be rejected out of hand by those clients who see it as too intertwined with Buddhism to fit their own values. While embedded practices solve some ethical quandaries about consent and values imposition, they raise other issues. For instance, many spiritual exercises and rituals, especially interventions from beyond, must be conducted or supervised by clergy. Since most therapists are not clergy, invoking them would be usurping the place of clergy. Even in the cases in which therapists are clergy from the same tradition, engaging in these practices (e.g., absolution, blessing, etc.) raises unhelpful issues of boundaries and transference (Cooper-White, 2006). Embedded interventions can also call upon the therapist to step into the role of expert or teacher, which often requires additional training in theology, spirituality, or practice. While pastoral counselors may have this training, it is not a widespread part of clinical education. Finally, the function of R/S interventions can change through their use in therapy. In this way, it is not apparent that anything invoked in a clinical setting can actually count as embedded—praying for therapeutic reasons can become praying solely for therapeutic reasons. Disembedded Interventions Since embedded interventions run the risk of creating conflict or boundary issues where there might not need to be any, disembedded interventions can be attractive in many circumstances. The intent of secularizing interventions is to identify exercises embedded in wisdom traditions that have proven effective across time and culture and to offer them in a way that preserves their benefits without requiring the therapist or client to endorse any particular metaphysical scheme, which would pose ethical challenges. Another benefit of this strategy is that in not directly invoking traditions, sources of resistance are diminished that come from wariness of orthodoxy or desirability to be seen as a model believer. Finally, this strategy also identifies the aspects of these exercises that are most amenable to empirical measurement and analysis and therefore in building scientific knowledge about the mechanisms through which they operate. To see how this strategy has been pursued, consider the case of mindfulness. Right mindfulness is one of the dimensions of the eightfold path originally taught by the Buddha and still universally accepted among Buddhists of all traditions. Thus, mindfulness is a part of a much larger whole of spiritual living. It is a means for liberation, a constituent of the three higher educations (triśikṣa) expressed in the practices of the eightfold path: training in wisdom, morality, and concentration.

86  Ways of Intervening When mindfulness was introduced to Western circles, the grand picture of liberation from rebirth into suffering (saṃsāra) was intentionally omitted. This choice was made by the person credited with introducing mindfulness to Western medical and psychological milieus, John Kabat-Zinn. Coming from the perspective of both a dharma teacher and medical doctor, Kabat-Zinn believed that mindfulness could foster health-promoting effects. However, he was also deeply skeptical that his colleagues at Massachusetts Medical School would quickly dismiss his methods because of their Buddhist context. Rather than decontextualize mindfulness from its Buddhist mile, Kabat-Zinn sought to recontextualize it in such a way that it would meet the stringent standards of Western science, including psychiatry and psychology. Mindfulness most often is operationally defined as a mode of consciousness consisting of “the state of being attentive to and aware of what is taking place in the present” (Brown & Ryan, 2003, p. 822) in a “nonjudgmental or accepting way” (Lilja et al., 2011, p. 292). The operationalization of mindfulness encouraged a proliferation of assessment tools to measure it in a broad range of clinical and non-clinical contexts, and in a variety of languages. Empirical studies of mindfulness have supported the general conclusion that mindfulness practices and meditation can meaningfully influence the experience of mindfulness itself (Eberth & Sedlmeir, 2012). While most of this evidence has never focused on the broader goals of Buddhism per se, it has provided significant support for health benefits of mindfulness in other ways that are broadly applicable and have obviously elicited enthusiasm from clinicians and the general public. Despite the obvious benefits of the therapeutic use of “mindfulness,” it also demonstrates the shortcomings of disembedded interventions. First, there is a real ethical conundrum of whether bracketing the metaphysical and religious nature of these interventions meets the criterion of informed consent; a conservative Christian client who is trained in loving-kindness meditation and later finds out its Buddhist origins is likely to feel betrayed by the therapist. This omission could provide the basis for tangible therapeutic harm. Second, it is not entirely clear that the interventions labeled “mindfulness,” “forgiveness,” etc., are actually the same as their embedded counterparts. For instance, Buddhist scholars have pointed out the weakness of many formulations of “mindfulness” in the psychotherapeutic literature, suggesting that these researchers have “insufficiently addressed distinctions between their own characterizations of mindfulness and general Buddhist definitions” (Grossman & van Dam, 2011, p. 222) and that “discussing mindfulness without including other integral aspects of Buddhist practice . . . may lead to significant denaturing of mindfulness” (p. 223). This critique suggests that R/S integrated psychotherapy needs

Ways of Intervening 87 more precise language for how it is engaging R/S interventions in order to make the relative strengths and pitfalls of each approach clear. Tools vs. Practices A helpful way of thinking through the difference between embedded and disembedded interventions comes from philosophical virtue ethics (Stewart-Sicking, 2008). In exploring how to describe human excellence and a life well lived, the philosopher Alasdair MacIntyre (1984) developed a framework of virtue, practice, tradition, and narrative selfhood, each of which is interconnected with the others. For this discussion, it is useful to consider the first three of these concepts. Virtues are dispositions that both make it possible for individuals to pursue the good life and to incline them in its direction. In classical philosophy, these include qualities such as prudence, temperance, fortitude, and courage (Aristotle, 1974). This concept is familiar to therapists from developmental psychology, such as in Erikson and Erikson’s (1998) identification of the developmental virtues of hope, will, purpose, confidence, fidelity, love, care, and wisdom, corresponding to the successful resolution of each developmental conflict. Just as counselors harness and develop the virtues of healthy psychosocial development through their interventions, counseling interventions drawn from R/S also interact with virtues such as mindfulness, compassion, imperturbability, commitment, and the like. Practices are the ways one builds and exhibits virtue through repeated action. MacIntyre (1984) defined practices as cooperative, complex activities in which people strive to achieve standards of excellence, to gain the “internal goods” that can only be achieved through the practice, and to expand human abilities and wisdom. Many of the R/S interventions utilized in psychotherapy are practices in this special sense: they are something that take time to master and are worth doing not just for the way they make one feel, but for their own sake. The third piece of MacIntyre’s (1984) model is tradition, “an historically extended, socially embodied argument, and an argument precisely in part about the goods which constitute that tradition” (p. 222). Traditions provide guidance for how to live wisely to which practitioners are accountable. They are often preserved in classic writings and in communities of practitioners. It is precisely in eliminating the links to tradition, virtue, and the internal goods of practice that disembedded interventions differ from embedded ones. Instead of practices, disembedded interventions are more like tools than practices. A secular gratitude intervention (e.g., Emmons & Stern, 2013) can be taught and used as a way to improve positive affect and thus broaden and build (Fredrickson, 2001) a wider range of coping

88  Ways of Intervening responses. However, beyond reducing suffering—itself a very important goal—it is not clear to the client why gratitude might be worth doing for its own sake, how one might grow in the complexity and impact of this practice (including its spiritual trajectory), and how it might fit into living one’s entire life well. Without context, the connection of this activity to the life well lived—its true purpose—is not evident. Providing R/S interventions without a context in tradition is a bit like teaching someone how to play scales on a piano without reading music or even hearing a concert. To make a sound, this intervention is perfectly adequate. It will work; the student will enjoy it and feel successful. And if that is the entire purpose of the exercise—to have experienced playing a piano—then there is no reason for concern. But what if playing the scale kindles a desire to make more music on the part of the student? What if the student falls in love with the piano, but runs up against challenges in what to do next? Certainly, the student could improvise and have some new experiences. However, there is an entire world that could be opened up to them if they were to have a teacher. In the same way, practicing gratitude so as to have a more positive daily experience of life might be appropriate to many therapeutic relationships. But what if the gratitude exercise awakens a spiritual longing, or worse, what if it raises difficult spiritual questions? There needs to be a way to judge when embedded vs. disembedded interventions are appropriate, and what to do in cases in which new issues are raised. Openness to Development What differentiates ethical from problematic disembedded interventions is whether the use of those interventions remains open to the trajectory of positive development in the tradition from which they are excerpted. Counselors should not become spiritual directors and focus their efforts with their clients on the details of spiritual development and practice. However, when therapists become custodians of R/S practices through utilizing them for therapeutic benefits, they must exercise care that they preserve the ability of these practices to lead to spiritual development that a client could pursue with a spiritual director if so inclined. Otherwise, the practice is not merely transplanted to a new environment, but it has been uprooted. Again, mindfulness, the most popular R/S intervention (and one commonly disembedded), proves instructive. Too often, mindfulness techniques seem to be joined to a Western philosophy of engineering the self. However, as we said in Chapter 2, at the heart of Buddhism is the dharma that the self is a fiction, one that causes suffering. As one Buddhist psychotherapist notes: Meditation is being appropriated for the worthwhile purposes of increasing awareness, reducing stress, and enhancing the quality and

Ways of Intervening 89 functioning of our personal lives. At the same time, it gets woven into the individualistic narrative of our lives. Hence meditation, as it contributes to positive internal experiences, can easily become significant in the service of our individualistic agendas for success. . . . Such considerations affect what is focused on and presented from the Buddhist tradition. (Aronson, 2005, pp. 28–29) The use of interventions such as mindfulness risks engaging in cultural appropriation, where they become a tool of success much like any other commodity. There are many positive uses of R/S interventions in psychotherapy, but therapists must also be careful not to turn these interventions against their own traditional purposes, but to allow these purposes to express themselves if appropriate in the client’s life. Scholars have suggested ways to avoid appropriation, including recognizing when R/S practices become more about spiritual bypass rather than their full range of breadth and depth of purposes, understanding the desired effect (from the perspective of the client) of the practice itself, matching the intervention to the client’s contexts which could include using another practice more consistent with the client’s R/S, and engaging in reflexivity through reflection on the following questions: • How have I come to know this practice? Who were my mentors, instructors, and educators, and in what ways are their values or contexts affecting my understanding? • Who am I in relation to this practice? In what ways do my privilege, culture, faith orientation, and values influence my use of this practice? • What do I believe about this practice? What do I know about this practice, and what opportunities exist for additional understanding? • Why is this practice of value to me? In what personal, financial, and professional ways will I benefit from this practice? (Adapted from Surmitis, Fox, & Gutierrez, 2018, p. 13) Psychotherapy has often followed this advice, even if not in these explicit terms. For instance, Twelve Step spirituality is often utilized as an adjoint to other therapeutic practices. Addictions counselors do not focus on navigating the spiritual awakening that comes from working the steps (that is the role of the sponsor), but they also do not attempt to short circuit this process from happening. Some mindfulness-based therapies have also explicitly attempted to account for the growth in spirituality toward one’s values that can come with treatment. For instance, the commitment aspects of ACT are dedicated to helping the client articulate personal values and commit to living out these values and growing in them (Hayes, Strosahl & Wilson, 2016).

90  Ways of Intervening The journey of psychotherapy often leads clients past portals to spiritual development. This is to be expected when engaging R/S interventions. The role of the therapist is not usually to walk through those doorways with clients, but to create conditions in which they can be noticed and opened if the client wishes to do so. Spiritual development is not always pleasant, and wisdom traditions have long noted that we do much better if we entrust ourselves to a guide. Counselors should have basic referral resources for those clients once they walk down those pathways.

Case Example: Tracey As outlined previously, R/S interventions in psychotherapy have several dimensions that can come into play when making a clinical decision: the level of the ecosystem, the level of transformation, the dimension of experience engaged, and the embeddedness within a tradition. While some combinations of dimensions have been the topic of more research, there is evidence of efficacy for interventions across the spectrum. This classification strategy also shows areas in need of further research, and especially research (both quantitative and qualitative) on the interaction of these dimensions and the conditions under which they are effective. As this research body develops, we will have a more detailed understanding of how to choose an intervention for specific presenting problems. However, just as in the case of psychotherapy more generally, empirical support does not eliminate the need for practical wisdom in deciding when and how to intervene. The following case study demonstrates some of the ways in which this comes into play. Tracey is a 48-year-old African American woman who identifies as a Pentecostal Christian. She has been struggling with the symptoms of complex PTSD for many years: flashbacks, avoiding situations, difficulty sleeping, feeling as if her surroundings were unreal, and a long history of shame around her body and sex. While she has had good and bad periods in her struggles over the years, she has been very reluctant to seek out a counselor, since she believes that the power of prayer and fasting has cured her in the past. Recently, a trusted friend from church started getting a counseling degree and convinced her to come into therapy. Much of your early relationship building with Tracey revolved around whether she would trust you to respect her faith. Now, she usually feels free to share that part of her life, and you have learned that she was sexually abused over a period of two years by a pastor, starting when she was 11. She tends to explain her symptoms in terms of spiritual combat with demonic forces, but she has become discouraged after prayer and layingon of hands at her church have not made a difference. She blames her weak faith, but you also suspect that she blames God. She keeps returning to the scripture Isaiah 26:3, “Thou wilt keep him in perfect peace,

Ways of Intervening 91 whose mind is stayed on thee: because he trusteth in thee” (KJV). She thinks she just hasn’t let herself trust God enough to heal her. Treatment for complex trauma is multifaceted and multidimensional (e.g., Ford, Courtois, Steele, Hart, & Nijenhuis, 2005). You are likely to include strategies for affect regulation, encountering and processing experience, addressing intrusive thinking patterns, and creating a new global sense of meaning. Several of these could involve R/S interventions. It is important to remember that there are many therapeutic paths forward that are probably equally effective and healing; any one specific choice will not make or break treatment, especially in the presence of strong relationship. How then would you think about what types of R/S interventions might be appropriate or avoided? • Level of system: Because the trauma was perpetrated by a clergy member, there is the potential for the desecration (Pargament et al., 2005) of this system. For this reason, it seems wise to begin by focusing on the microsystem. • Level of critical reflection: Again, because of the desecration that has occurred, R/S interventions will likely need to be transformational. You might look at problems with Tracey’s use of a single scripture, utilizing Socratic questioning or knowledge of what some other clients have found comforting. Healing R/S themes seen in working with this population include identifying moments of divine healing, openness to a transformed relationship to God, sharing one’s experience as a way of helping others, and engaging in forgiving (Covington, 2017). • Level of experience engaged: Treating complex trauma progresses from strengthening the therapeutic relationship to processing the trauma to rebuilding daily living skills (Ford et al., 2005). Interventions from below might match the second phase—for instance, imagining the presence of a loving and powerful God. Interventions from above might fit the third phase, such as R/S sense-remaking and recalibrating the use of scripture to help with distressing thought patterns. • Embedded or disembedded: Given Tracey’s level of religious devotion, embedded practices seem like the likely place to begin, being careful not to contradict her tradition’s use of those practices or make them one-dimensional.

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5 Assessment and Case Formulation

Assessing the varieties of R/S dates back to James’s (1902/1936) phenomenological account of “once born” healthy-minded persons and “twice born” sick souls. Since then, other heuristic categories have followed, such as authoritarian and humanistic religion (Fromm, 1950), intrinsic and extrinsic religiousness (Allport & Ross, 1967), and theistic and nontheistic R/S (Pargament & Mahoney, 2005). More recently, polls abound with categories assigned to the moving target of American religious and spiritual identities, prompting a typology approach to understanding these sociological shifts (religious, spiritual but not religious, intellectual atheist, seeker agnostic, etc.). Useful and compelling as these typologies may be for understanding demographics, assessing R/S in therapy requires more than just recognizing cultural trends or even selfprofessing identity frameworks. The everyday functions and meanings of these R/S subcultures and the roles they play in clients’ languishing and flourishing must also be understood. For this, in-depth assessment is needed. The structure of case formulation provides a preliminary step toward that end. Case formulation is a pragmatic process of synthesizing assessment information into a holistic map, for the purpose of (a) understanding client issues and strengths and (b) developing treatment plans and tracking progress. Each piece builds onto the next. Effective treatment is built on effective case formulation, which is built on effective assessment. Holistic approaches to case formulation, such as Sperry and Sperry’s model (2012), include the four dimensions of diagnosis, clinical, cultural, and treatment conceptualizations, each with its own question. The question of “what can be done” answered by the final dimension of the treatment conceptualization builds on the first three (Table 5.1). To reiterate, case formulation structures assessment, which provides the foundation for effective treatment planning. Assessment and case formulation involve competing pressures to be thorough and tailored to the client, yet brief and grounded in empirically supported treatments (Norcross & Lambert, 2018; Sommers-Flanagan & Sommers-Flanagan, 2017). The push to adopt a one-size-fits-all standardized

98  Assessment and Case Formulation Table 5.1  Case Formulation Diagnostic formulation Clinical formulation Cultural formulation Treatment formulation

What happened to cause the distress? Why did the distress happen? What role does culture play? What can be done?

(Adapted from Sperry & Sperry, 2012)

approach to treatment is just one of the challenges therapists face. Adding R/S to an already lengthy list of case formulation elements (see, e.g., 17 elements in Sperry & Sperry, 2012) may feel cumbersome, but a growing body of research suggests this is what many clients want (Harris, Randolph, & Gordon, 2016) and indeed benefit from (Captari et al., 2018). The role R/S plays in core problems and solutions is too essential to be overlooked (Griffith & Griffith, 2002; Pargament, 2011). Assessing clients’ R/S is integral to effectively tailoring therapy to the client (Norcross & Lambert, 2018). Best practices and ethical standards across the allied helping professions accept assessment of R/S as normative practice. Notwithstanding the acceptance of the need for assessing R/S in therapy, many challenges complicate this process. The goal of this chapter is to introduce the reader to a holistic formulation of R/S issues in counseling that uses the Ways Paradigm. First, in an effort to set the stage for the unique contributions of the current model, some of the challenges that beset assessment are reviewed. We also discuss how existing models address these challenges through stages of tacit, initial, implicit, and explicit assessment. Next, the focus shifts to the Ways Paradigm model of assessment. We apply the ways paradigm to assess common R/S constructs and tease out their cognitive (understanding), affective (being), and behavioral (intervening) aspects, leading to a case conceptualization tool that considers a client’s resources and challenges. Finally, we apply this tool to a variety of case examples to demonstrate how to use it to guide practice.

Finding Self-Awareness through Tacit Self-Assessment The primary challenge to assessing R/S concerns the difficult task of knowing oneself. Working with R/S, much like other multicultural topics, such as race or sexual orientation, involves unacknowledged biases. Aphorisms, such as “you don’t know what you don’t know” and “there’s no such thing as a view from nowhere, only now-here,” invite awareness of these inherited biases. Likewise, just as topics, such as parental relationships or death frequently come loaded with unresolved wounds, so it is with R/S. In sum, no matter the therapists’ theistic stance, R/S tradition, or metaphysical philosophy, all bring some sort of view. And not

Assessment and Case Formulation 99 uncommonly, R/S views are supercharged with emotion. No approach to assessment is without its hazards, but developing awareness of one’s assumptions helps prevent clashes among worldviews that foreclose on healing dialogue. The challenge of self-awareness is addressed through tacit self-assessment. Tacit Self-Assessment Self-awareness is too important not to be included as part of assessing R/S. Consistent with many of the concepts we introduced in Ways of Being, tacit self-assessment aims at awareness of the assumptions we bring into session—what we do through. Effective assessment begins with comprehensive self-assessment of the ultimate values that have slowly and unconsciously become “a part of their [therapists] being and thought and sense of their own identity” (Berlin, 1969, p. 172). These values shape how our being is formed and how we encounter the world. The tacit highlights that “much of what we accept as normative is deeply anchored in our past and identity” (Taylor, 2007, p. 582). To summarize the goal of tacit self-assessment, “this critical focus on the self is about learning how to be present and encounter the mystery of the other, without projecting and inflicting our own unresolved R/S difficulties on those seeking care” (Deal & Magyar-Russell, 2015, p. 117). Identifying tacit assumptions and values is a prerequisite for offering a space of genuine curiosity able to empathize with the client’s R/S world. These assumptions are partially revealed and concealed in the questions asked and unasked during assessment. For instance, asking about clients’ religious upbringing, but not their spirituality may reveal an assumption the two are synonymous. Learning to attend to the tacit is a process connected to the overall quality of our conceptualization, assessment, and diagnosis of religion and spirituality in psychotherapy. A number of informal assessment tools exist for developing tacit awareness. The invitation provided by Sperry and Mansager (2007) is for clinicians to get acquainted with the “metaphysical, spiritual assumptions that they bring to the therapeutic discourse” (Sperry & Shafranske, 2009, p. 24). They offer five positions, which vary according to (a) whether the psychological and R/S dimensions are the same or different, and (b) which dimension has primacy. They are that: (1) psychology and R/S are the same, with the psychological having primacy; (2) psychology and R/S are the same, with the spiritual having primacy; (3) psychology and R/S are different, but overlapping at times, with the psychological having primacy; (4) psychology and R/S are different, but overlapping at times, with the spiritual having primacy; and (5) psychology and R/S are

100  Assessment and Case Formulation different, yet neither has primacy (nor is reducible to the other). If, for example, a therapist is aware they operate from position three and the intake indicates the client’s frame resembles position two, then including a spiritual autobiography may serve as useful in taking a psychosocial history. For all possible combinations of Sperry and Mansager’s (2007) positions, clarifying the assumptions of one’s worldview facilitates an empathic and ethical therapeutic encounter; one where real difference is grasped and values are noted, but bracketed in order to enter the client’s world. R/S Transference and Countertransference Working with R/S issues stirs up transference and countertransference dynamics that Jordan (1986) named colluding, colliding, and collaborating. Collusion occurs when therapists assume they grasp the clients’ R/S meanings, which interrupts empathy and forecloses exploration (Morrison & Borgen, 2010). In collusion a kind of spiritual blindness may result where points of common ground obscure significant differences (Shafranske, 2013, p. 596). Collision occurs when the therapist’s underexplored assumptions crash into the client’s R/S worldview in ways that may produce empathic ruptures in the relationship, leading to problematic dynamics, such as spiritual intolerance and spiritual exclusivism (Pargament, 2007, p. 187). The ideal approach of collaboration, the critically conscious work of appreciating differences and commonalities between therapist and client, is facilitated by tacit self-awareness. Yet, there remains the challenge of how best to collaborate. Johnson (2013) recommends focusing on “client defined spirituality,” which essentially means inquiring into and working with the various and unique ways clients talk about their spirituality. He provides a series of self-reflection questions to help therapists develop the prerequisite self-awareness for nonjudgmentally adopting the client’s language: 1. What were your experiences of spirituality when you were growing up? 2. What were you taught about God or a higher power? 3. What has been your spiritual journey in relation to what you were taught as a child/teenager? 4. Have you experienced any judgment, oppression, or violence in the context of your spirituality? 5. Do you think you have the right way of considering and practicing spirituality? 6. How open are you to your clients’ unique and personal ways of defining, experiencing, and accessing spirituality?

Assessment and Case Formulation 101 Other ways to develop tacit self-awareness include three self-exploration activities identified by Hagedorn and Hartwig Moorhead (2011). The first activity aims at global self-reflection and includes exploring questions through journaling, meditation, or small groups. For example: 1. What were the specific religious/spiritual beliefs and values of my parents (or my family of origin)? (A family tree or a religious/spiritual genogram may be constructed to track the development of religious/spiritual beliefs and values.) 2. Where and when were some of the turning points in the development of my religious/spiritual beliefs and values? 3. Where am I now on my religious/spiritual journey? The second activity aims at focused self-reflection in response to reviewing sessions. Journaling is recommended, but supervision would also suffice as a forum to explore questions such as: 1. How did my personal beliefs manifest in session? 2. What areas of self-awareness do I need to develop as a result of evaluating my performance? 3. Am I able to create spiritually safe and affirming therapeutic environments for clients? 4. How comfortable am I exploring my client’s spiritual or religious beliefs? 5. How did my actions encourage or hinder the degree of exploration of spiritual or religious issues during the session? Finally, the third activity aims at developing resources in the form of a consultation and referral list (adapted from Faiver, O’Brien, & McNally, 1998). No matter how motivated or skilled, therapists have limits preventing them from being all things to all people. The following offer some guidelines: 1. Ask colleagues where they have referred clients and with whom they consulted. 2. Contact members of various faith communities; clergy are often excited to connect with counselors who are interested and able to work with their congregants. 3. Connect with governing councils of local churches, synagogues, and temples (or groups that fulfill this role in communities) as valuable information sources. Therapists who have sufficiently explored the tacit dimension demonstrate the four essential qualities of spiritual knowledge, openness and tolerance,

102  Assessment and Case Formulation self-awareness, and authenticity. As such, they are less likely to persist in the common problems clinicians bring to assessing R/S, such as spiritual intolerance, illiteracy, bias, myopia, timidity, overenthusiasm, and cockiness (Pargament, 2007). Working through tacit self-assessment increases multicultural sensitivity and minimizes the odds of being caught off guard by implicit biases and unresolved issues, but other challenges still remain.

Initial Assessment as a Way to Begin Venturing into the territory of assessing R/S is fraught with concerns about overstepping and appearing judgmental. Perhaps the first challenge to doing R/S assessment is knowing how and where to begin. Therapists may wonder if clients will be offended or relieved by the invitation to explore this topic. Which points are essential and which are extraneous? Which questions gather essential information, without lingering too long or probing too deeply, too soon? What if the client asks about one’s own R/S? Not surprisingly, some clinicians would sooner assess trauma than R/S. Not knowing how and where to begin is a daunting task. However, as Griffith and Griffith (2002) asserted, the key to assessing R/S is about learning to listen more than asking the right question. While listening for the psychospiritual themes, Pargament’s (2011) model offers four categories/questions to guide the initial assessment: 1. Salience of spirituality Do you see yourself as a religious or spiritual person? If so, in what way? 2. Religious affiliation Are you affiliated with a religious or spiritual denomination of community? If so, which one? 3. Relationship to the problem Has your problem affected you religiously or spiritually? If so, in what way? 4. Relationship to the solution Has our religion or spirituality been involved in the way you have coped with your problem? If so, in what way? These questions fit within the intake process alongside the assessment of other multicultural and biopsychosocial topics. Together, they combine to give a quick overview of the need for additional assessment. According to Pargament’s (2011) model, when clients answer in the affirmative, clinicians should move on to an in-depth, explicit R/S assessment. When the salience of R/S is denied, implicit assessment is the next step.

Assessment and Case Formulation 103 Implicit Spiritual Assessment as Exploring Ultimate Concerns Next is the challenge of assessing the latent R/S strivings, values, and meanings in those less versed or comfortable with what is traditionally considered R/S. The rationale for implicit assessment is ultimate concerns need not be consciously recognized as R/S to act as sources of distress, coping, and/or flourishing. Broad and inclusive as Ammerman’s (2013) working definition of R/S as “transcendent, sacred, or beyond the ordinary” may be, not all clients will resonate with this language. Ultimate concerns and transcendent strivings extend well beyond the purview of R/S traditionally defined. Implicit assessment addresses the need to explore parts of the human experience that tap the dynamics and functions of R/S without applying an R/S vocabulary. As Tan (1996) wrote, these approaches neither “initiate the discussion of religious or spiritual issues” nor “openly, directly, or systematically use spiritual resources” (p. 368). Several examples in the extant literature provide guidance to this end (Canda & Furman, 2010; Clinebell, 1984; Deal & Magyar-Russell, 2015; Hodge, 2013; Pargament, 2007). Some of the main points are summarized next. Several assumptions ground implicit assessment. First, spirituality— one’s sense of what is sacred, transcendent, or beyond the ordinary—is an essential quality of the overall human experience (Pargament, 2011). Second, the spiritual and psychological dimensions of human experience are related (Sperry & Mansager, 2007). Thus, exploring psychological experiences of ultimate significance is a way of understanding lived experiences of R/S. Third, implicit assessment builds on the tacit dimension. When tacit self-awareness is lacking, R/S may be limited to one’s inherited biases and experiences. Implicit approaches draw principally on functionalism and phenomenology in that they explore the functions of R/S as they are experienced and lived in everyday life. This provides a respectful and inclusive way to get acquainted with the latent spiritual qualities of the client’s narrative through their preferred language. Understanding R/S functionally is a widely applicable method of assessment because it expands beyond traditionally religious content to explore the psychospiritual meanings derived through one’s ultimate concerns. Examples of the implicit functions R/S serve include passion, meaning, purpose, coherence, identity, vitality, resilience, transformation, etc., but there is no definitive list. Pargament (2007) suggests sacred qualities such as peace, courage, solace, sustenance, devotion, faith, hope, love, letting go, forgiveness, regrets, despair, and suffering. According to Elkins’ (1998) study of spiritual phenomenology, some of the essential qualities to consider include: transcendent dimension, meaning and purpose in life, mission in life, sacredness of life, spiritual vs. material values, altruism, idealism, awareness of the tragic, and fruits of spirituality. Elkins (1998) also identifies eight paths along which clients might express and

104  Assessment and Case Formulation experience their spirituality, such as the feminine, the arts, the body, psychology, mythology, nature, relationships, and dark nights of the soul. One broadly defined starting place for approaching implicit assessment are experiences that are consciously or unconsciously set apart as special and significant (Taves, 2010), whether of the ordinary (appreciating art) or extraordinary variety (moments of oneness-with-everything). Another option is to frame clients’ strivings as manifestations of the spiritual quest for “the more” (James, 1902/1936). Whether clients are searching for more relaxation, self-discipline, freedom, connection, fulfillment, selfcompassion, “Nested within these searches for more are the raw materials for bridges yet to be built: to deeper meaning, significance, and the possibility of sacred discovery” (Deal & Magyar-Russell, 2015, p. 125). Whatever the more one longs for, it is an opportunity to re-evaluate deeper longings for significance. Classic names given to mysterious experiences of the more include “peak” (Maslow, 1964), “mystical” (James, 1902/1936), and “numinous” (Otto, 2012) experiences. Assessing such experiences functionally may be done through exploring spiritual emotions, such as wonder, awe, reverence, elation, gratitude, and others. James’s (1902/1936) concept of the more is frequently discussed in R/S discourse through the construct of transcendence. In the broadest sense of the word, assessing transcendence means evaluating if, and how, clients feel they are a part of something greater than the self. Beyond this common ground, variegated meanings abound. Two such categories for organizing these meanings are ontology and phenomenology. As an ontology, transcendence means transcendent reality. The meaning of clients’ transcendent realities depends on whether they are operating from a dualist, monist, or nondualist framework. Dualist conceptions tend to cast transcendence in opposition to immanence. The transcendent is out there beyond the immanent world. Theistic understandings of the Abrahamic faiths often operate within dualist ontologies. Monist conceptions do not divide reality into a dichotomy, but rather view all of the immanent cosmos as part of one great unified and transcendent reality without remainder. Pantheism is one such example. The early philosopher Origen illustrated monism in the quote, “The cosmos is a huge animate being held together by one Soul” (as cited in McFague, 1993, p. 32). Nondual approaches, commonly found in contemplative and mystical traditions, view transcendent reality as both multiplicitous immanence and transcendent unity. Reality is both one vast interconnected whole in which one may lose themselves and a multitude of separate and individual beings all sharing interbeing (Hanh, 1992). Nondual perception accepts that reality includes both dual and monist aspects (Michaelson, 2013). What is critical to these three understandings is how they frame the ways transcendence and immanence interact in human experiences. In dualist conceptions, transcendence may be encountered through hierophanies (Eliade, 1987), which are experiences where a transcendent reality

Assessment and Case Formulation 105 ruptures the immanent frame. In both monistic and nondual understandings, transcendence is already a quality of the world as in horizontal or immanent transcendence (Goodenough, 2001; Deal & Magyar-Russell, 2018). Transcendence may also be conceptualized phenomenologically in terms of lived experience, rather than as an ontological reality of belief. About this, Taylor (1991) notes, “Just because we no longer believe in the doctrines of the Great Chain of Being. . . . We may still need to see ourselves as part of a larger order that can make claims on us . . .” (p. 89). Lived experiences of this larger order might be felt as “expansive ways of feeling and thinking that deflate the self by inflating that with which the self partakes” (Flanagan, 2007, p. 52). Or, they might be experienced as a sense of “connection to something higher . . . that there is meaning or purpose larger than ourselves” (Peterson & Seligman, 2004, p. 38). Yet another description casts transcendence as a “universal urge . . . to seek to transcend a narrow, local, occluded view of the world . . . and to locate a wider, broader, deeper way of making sense of things and finding meaning” (Flanagan, 2007, p. 187). Though experiences of transcendence vary in salience and intensity, they often share common themes, including ineffability, noetic quality, transiency, unity, sacredness, deeply felt positive mood, and transcending time and space (Pahnke, 1966; Richards, 2016). These two frameworks of ontology and phenomenology frame important assessment questions about how clients locate, conceptualize, and experience this mysterious sense of the more. Is it part of the here and now of the immanent world or primarily a transcendent reality beyond the world? What meanings have been made out of the experience? Finally, no matter how a client identifies their experiences of the more, what lasting effects remain, if any? Practically speaking, Griffith and Griffith (2002, p. 46) recommend a variety of practical “existential questions” able to draw out the implicit R/S dimension: • • • • • • • • • •

What has sustained you? From what sources do you draw strength in order to cope? Where do you find peace? Who truly understands your situation? When you are afraid or are in pain, how do you find comfort? For what are you deeply grateful? What is your clearest sense of the meaning of your life at this time? Why is it important that you are alive? To what or whom are you most devoted? To who, or what, do you most freely express love?

Fleshing out R/S qualities embedded in everyday behavior also helps clients understand how they experience a sense of meaning and enchantment,

106  Assessment and Case Formulation draw on resources during difficult times, and connect and participate in a self-transcending story or purpose. Given the difficulty many experience today with characterizing their sense of R/S (Murray & Nielsen, 2006), implicit approaches may support clients with identifying and cultivating these resources. As Taylor (2007) speculated and Heelas (2008) observed, what begins as an implicit spiritual quest for self-realization or momentary bliss may yet evolve into explicit forms of R/S.

Explicit Assessment as Going All in As the adage about politics and religion goes, the risks of broaching religion directly are significant. Developing tacit awareness, assessing the salience of R/S with initial questions, and listening for implicit spiritual qualities and themes equip therapists with multiple tools. Yet, when the initial steps indicate that extensive R/S assessment is warranted, the need for specific and concrete tools remains. For the growing demographic of unchurched and nonreligious therapists, this step is comparable to entering a foreign culture. Explicit assessment structures this process. Its aim is to develop a thorough understanding of the role of R/S practices, experiences, rituals, and/or knowledge play in problems and their resolution (Hodge, 2013; Pargament, 2007). Fortunately, the literature on explicit assessment is extensive. Explicit Assessment Explicit assessment modalities should be selected based on the needs of the client, the setting, and the therapist’s knowledge and abilities. Some of these modalities include (a) open-ended questions for drawing out the R/S history, current story, future ambitions, beliefs and attitudes, and practices and experiences; (b) quantitative instruments; and (c) tools that facilitate visual diagrams (Hodge, 2013). Explicit open-ended questions are designed to invite the client’s R/S story across several important domains. Rather than merely answer topical questions about R/S affiliation or behaviors, they aim to explore the depth and richness of the R/S story. The following questions provide a sample of explicit assessment questions adapted from Pargament’s (2007) spiritually integrated psychotherapy: • Describe the R/S tradition you grew up in. How did your family express its R/S? • When did you first discover or learn about the sacred? • What do you see yourself striving for now and how does your R/S fit in? • Why do you think you’re involved in R/S?

Assessment and Case Formulation 107 •

When do you feel the presence of your R/S in your life most strongly? • Do you ever have mixed thoughts and feelings about your R/S? What are they like?

• • • •

What has helped nurture your R/S? What has been damaging to your R/S? What aspects of your R/S have been particularly uplifting? How has your spirituality changed your life for the better and for the worse? • To what extent has your R/S been a source of hard feelings, such as pain, anger, guilt, fear, etc.? Explicit R/S questions clarify some of the resources and vulnerabilities set within clients’ greater life story. These are not cordoned off from the problems and solutions clients bring to therapy, and thus, have direct bearing on the quality and efficacy of the therapeutic relationship. Quantitative assessments to evaluate a client’s R/S life are legion (Hill & Hood, 1999). These assessment tools span several forms of methodology, including self-report and observer rating, and vary in terms of their psychometric rigor. What they hold in common, however, is that they are measuring beliefs, attitudes, emotions, and behaviors of uniquely R/S significance. As is discussed in Chapter 8, psychometricians who have developed these instruments would have to acknowledge that they are not measuring “God,” but rather the subjective experience of such realities by means of directly observable phenomena. (See Hill& Edwards, 2013, for a review of measures.) Last, there are many visual diagrams, such as spiritual ecomaps, life maps, or genograms, which can help add context to their clients’ R/S (Hodge & Holtrop, 2002; Hodge, 2013). These visual diagrams are used conversationally through the assessment process, but focus explicitly on R/S histories and current contexts. For instance, in spiritual genograms, symbols can be adapted to identify religious affiliation or important R/S events of family members across generations. While they lack psychometric properties, these informal R/S assessment strategies are useful for going into depth with clients about their R/S well-being and placing the client into a larger R/S context that may significantly affect their current functioning. Essential to explicit assessment is a model of some kind of normative spiritual trajectory along which clients travel throughout their R/S journey. For instance, in Pargament’s model, the sacred is first discovered and conserved through various pathways, including practices, experience, beliefs, and community. During hard times, one may rely on conservational coping methods that keep one’s R/S orientation intact. If the threat is too severe for too long, spiritual struggles and disintegration

108  Assessment and Case Formulation can manifest problems in the client’s spiritual destinations and spiritual pathways. In other words, one’s R/S loses its ability to effectively assimilate life events. Alternatively, when new pathways are forged during hard times and one’s spiritual destination is sufficiently expanded to make meaning of the spiritual struggles, transformational spiritual coping results. Pargament’s (2007) multifaceted model guides the clinician with questions and scales for eliciting and evaluating key aspects common to clients’ spiritual journeys. This framework fits better with monotheistic than nontheistic R/S. To reiterate, awareness of bias, working within one’s competencies, and seeking consultation and additional training are imperative to working with clients’ R/S meaning systems in explicit ways. Arguably, as one moves from the initial, to implicit, to explicit assessment of R/S, the positive and negative stakes are raised, and more training is required. Additional discussion of how to develop these skills, including knowing when to consult and refer, are addressed in the diversity, ethics, and competencies chapters.

Assessing R/S Pluralism and the Ways Paradigm Holistic Assessment Tool R/S pluralism may be one of the biggest challenges to assessment. As Rorty (1994) argued, without common premises R/S is often a “conversation stopper.” Working with R/S as lived experiences of what is “sacred, transcendent, or beyond the ordinary” casts a wide-enough net to include the various ways clients live out their R/S in contemporary culture. What is needed now is a similarly comprehensive assessment approach, one sensitive to the heterogeneity between R/S cultural groups and within individuals’ narratives. The inclusive Ways Paradigm holistic assessment tool is a decisive step toward meeting this need. With so much important groundwork already done on the process of assessment—stages, guidelines, instruments, interventions—one place for further development is creating a holistic assessment tool for R/S content. The three dimensions of the ways paradigm provide such a tool. Ways of understanding focus on the cognitive, ways of being on the affective, and ways of intervening on the behavioral. The Ways Paradigm assessment tool brings a trifocal lens of thinking, feeling, and behaving to assess common R/S constructs in two important ways. First, it provides a trifocal lens for assessing the thoughts, feelings, and behaviors clients experience in their R/S challenges and resources. Two of the most common R/S constructs identified with challenges and resources are R/S coping (Pargament, 19972007) and R/S struggles (Exline & Rose, 2014). Second, this three-dimensional assessment is then used to inform the role R/S should play in the treatment formulation. No matter how a client’s R/S struggles and coping manifests, the Ways Paradigm provides a trifocal lens for

Assessment and Case Formulation 109 assessing the cognitive, affective, and behavioral domains therein, and addressing them in treatment.

Challenges and Resources There is no definitive list of common R/S constructs. Unlike the wide aperture of constructs investigated in research, psychotherapy narrows its focuses primarily to constructs related with clients’ challenges and resources, with the aim of creating effective treatment formulations. Under these two umbrella categories of challenges and resources are myriad R/S constructs. Two of the most common include R/S struggles and R/S coping. A pluralistic approach frames R/S challenges and resources as any of the thoughts, feelings, or behaviors clients associate with their sense of what is sacred, transcendent, or beyond the ordinary. In the following section, each the common R/S constructs of struggles and coping is discussed, including some of the many forms they may take. Several case studies follow to show how the Ways Paradigm can be applied. Religious and Spiritual Struggles R/S struggles represent experiences of distress linked to conflicts, tensions, and concerns about R/S (Exline, 2013; Exline & Rose, 2014). Summarizing the literature on struggles, Exline and Rose (2014) conclude that struggles associate with distress because they are “linked with other nonreligious variables that indicate problems in coping (e.g., fearful or depressive thinking, a lack of self-efficacy, and problems with social support)” (p. 383). They also surmise a positive feedback loop between struggle and distress, where one perpetuates the other. Factors such as substance abuse, depression and anxiety, narcissism, greater psychological distress, and lower well-being all associate with R/S struggles (see Exline, 2013 for review). In many traditions the difficulty of struggles may also precipitate pathways to change, such as with post-traumatic growth (Tedeschi, Shakespeare, Taku, & Calhoun, 2018) and transformational coping (Pargament, 2007). Six types of R/S struggles currently exist under three categories. The first category of supernatural struggles includes divine and demonic struggles. Divine struggles are problems related to one’s beliefs about a deity. Examples include anger toward God as a response to suffering, as well as feeling condemned, punished, or abandoned by a deity. Godimage (Lawrence, 1997; Raiya, Pargament, Mahoney, & Stein, 2008; Wood, Froh, & Geraghty, 2010), God representation, style of attachment to God (Beck & McDonald, 2004; Kirkpatrick & Shaver, 1992) are all constructs related to divine struggles worth assessing. Demonic struggles are characterized by perceptions that some form of supernatural evil is present in one’s life in the form of harassment or persecution.

110  Assessment and Case Formulation The second category of interpersonal struggles consist of tensions over R/S issues—LGBT topics, role of science, hermeneutical differences—that cause distress in relationships with others in and out of R/S communities, regardless of tradition. Severe interpersonal struggles may associate with shadow projection in the form of stigmatization, marginalization, and demonization of others. Negative religious coping (Pargament et al., 2000), religious strain (Exline, Yali, & Sanderson, 2000), and negative religious triangulation (Yanni, 2003) are three such constructs related to interpersonal struggles. In interpersonal struggles, people lose access to their R/S support systems and suffer the difficulty of loneliness and isolation. The final category of intrapersonal struggles includes three types— moral, doubt, and ultimate meaning—all of which center on internal conflicts over one’s beliefs, behaviors, and thoughts. Moral struggles consist of conflicts about failing to meet personal standards, such as wrestling with human limitations and/or behavior perceived as bad. Idealism, perfectionism, and scrupulosity may contribute to moral struggles. Doubt struggles have to do with feeling troubled by questions that undermine R/S certainty. Last, struggles with ultimate meaning focus on spiritual crisis of meaning and purpose for one’s life. Common constructs related to intrapersonal struggles include religious doubts (Altemeyer, 1988), scrupulosity (Abramowitz, Huppert, Cohen, Tolin, & Cahill, 2002), sacred loss and desecration (Pargament, Magyar, Benore, & Mahoney, 2005), and spiritual bypass (Fox, Cashwell, & Piciotto, 2017). The Religious and Spiritual Struggles Scale (Exline, Pargament, Grubbs, & Yali, 2014) measures each of the six R/S struggles identified previously. Though the aforementioned R/S struggles were developed with theism in mind, they may also generalize to various R/S identities, including agnostics and atheists (Sedlar et al., 2018). The intrapersonal struggles, in particular, could include struggles with unwholesome attachments to ego, certainty, and permanence found in contemplative traditions and Western Buddhism. Understanding how struggles manifest with other metaphysical constructions of ultimate reality, common to unaffiliated, spiritual but not religious, and nontheistic identities, such as fate, karma, the universe, Gaia, Chi, etc., are still needed. Religious and Spiritual Coping For this chapter, R/S coping refers to a category of response to distress that draws from a broad array of R/S resources, such as practices, experiences, relationships, knowledge, and strivings in order to sustain or enhance psychospiritual growth. Practices include various activities repeated with the intention of connecting to one’s R/S, such as types of prayer, meditation, yoga, outdoor hiking, readings, therapy, etc. Experiences might

Assessment and Case Formulation 111 include peak and mystical experiences. Relationships involve one’s R/S community and support system. Knowledge covers the belief systems and essential ideas that provide order, coherence, and meaning. Last, strivings include the authentic longings of the self or soul that when realized offer purpose and fulfillment. According to Pargament (2007), R/S coping may focus on conservation or transformation. Conservation coping grounds the person in their R/S foundations to sustain and nourish them during difficult times. It draws on existing resources. Transformational coping, by contrast, involves changes in the foundations of whatever one holds as sacred, transcendent, or beyond the ordinary. Old resources are employed, but new resources may be discovered too. Throughout life, transformational coping may be necessary to retain a living and practical R/S that is responsive and integrating of new events. Not all transformations are growth producing or successful, however. Some may languish in a prolonged state of R/S free fall between times of relative stability. In his work on the courage to be, Tillich (2000) alludes to the challenging road of transformational coping when he writes, “The courage to be is rooted in the God who appears when God has disappeared in the anxiety of doubt” (p. 190). Suffering via anxiousness and doubt are some of the costs transformational coping exacts. Much of the social science literature on R/S struggles and coping was developed with theism in mind. An expanding literature in Western Buddhism, humanistic, transpersonal, and earth-based spiritualities suggest that other syncretic and nontheistic examples are becoming more commonplace. Examples of various R/S identities are included later in several case studies on R/S struggles and coping.

Challenges of Assessment Adjudicating between Health and Unhealth Adjudicating between what is R/S health and unhealth is the first challenge, and it is something that can quickly surface in the course of therapy as we discussed in ways of intervening. One of the foundational purposes of a therapist is to work toward the alleviation of the client’s suffering and to facilitate growth toward well-being. Therapists therefore have a vested interest in assessing the client’s R/S health and how their R/S could either be a source of distress or interacts with or exacerbates the problems clients encounter. Many if not most therapists would agree with the perspective of Griffith and Griffith (2002): An awful irony of human life is the recognition that spiritual beliefs and practices intended as doorways into the wholeness of life and relationships, can as quickly become doorways to hell. In one

112  Assessment and Case Formulation cultural context, religious beliefs and spiritual practices provide resilience against suffering when all other methods have failed, but they become fashioned into instruments of torture in another context. The power of spirituality and religion must be respected but not idealized. (p. 218) But how can therapists make assessments of their client’s R/S well-being and by what standards of health? Except for the broadly defined V-code “Religious or Spiritual Problem,” the DSM-5 is relatively silent about R/S issues. However, this was not always the case. As we have shown, the history of psychology and R/S has drifted between deep engagement, to neglect, to open conflict. The diagnosis of mental disorders has mirrored this history. For instance, the composition of the DSM-3 and 3-R reflected these negative biases through the disproportionate focus on religiously based maladies, such as delusions and hallucinations (Richardson, 1993; Larson et al., 1993; Stoupas, Binensztok, & Sperry, 2018). In the most recent edition of the DSM-5 (APA, 2013), R/S issues have become less pathologized. The DSM-5 now recognizes that spiritual and religious problems may be a focus of clinical attention and may be documented as a V-Code. Moreover, the language referring to the R/S manifestation of psychopathology became more accommodating. For instance, the language regarding delusions and hallucinations makes exceptions in cases where the religious content is culturally accepted and is commonly held or experienced within the client’s religious group. The psychiatric definition of a delusion now includes the important clause that “The belief is not ordinarily accepted by other members of the person’s culture or subculture (i.e., it is not an article of religious faith)” (APA, 2013). What is normative for religious communities is now recognized by the DSM. Recognizing the cultural variability of R/S experiences and practices is a step forward, but it does not solve completely the dilemma clinicians face when they need to make assessments about their client’s R/S health. Outside the DSM, where does one find definitive and objective criteria to evaluate the healthiness or unhealthiness, maturity or immaturity, of clients’ R/S lives? Which domains and/or constructs should even be assessed? Is it healthy for a client to refuse a potentially lifesaving medical operation based upon their religious convictions? Should a client change their concept of God, the Sacred, or however they define the nature of ultimate reality to be more consistent with twenty-first–century science? Should a counselor encourage a couple to consider divorce, separation, or an open relationship when the partnership appears doomed even though such steps are not encouraged in their tradition or is considered a severe moral failing within their faith community? Can a client’s lack of acceptance of other religions be understood as inhabiting a lower stage of psychological development? Should the client’s reluctance to practice meditation or mindfulness be a sign of lack of openness or rigid beliefs?

Assessment and Case Formulation 113 Complicating the matter further, how does one assess R/S as a domain of mental health when faithfulness or liberation supersede wellness as the ultimate goal of R/S (Dueck & Reimer, 2009; Michaelson, 2013)? R/S health can also be a moving target from one subculture to the next. Some religious groups may prescribe a religious coping style of deferring human freedom, where in others harnessing freedom for self-direction may be normative (Pargament, 2007). Some link maturity with embracing the tragic dimension of life, others with bypassing and romanticizing it. Some see R/S health as leaning heavily into the immanence of the world, while others see it as an unwavering focus on transcendence. Some tie it to prosperous wealth, where others aim for non-attachment to material goods. Questions like these (and many more readers will likely be familiar with) are what makes assessing health and unhealth so challenging. Clearly, drawing the line that disambiguates the “pathological” from the “spiritual” is no simple task. As Taylor (2007) writes, “To worry endlessly about the meaning of an unease whose whole basis is really organic . . . is to have incurred unnecessary suffering. But to have tried to get rid of an unease that one really needed to understand is crippling” (p. 622). Discerning the difference between transformational suffering and stagnating suffering is tantamount to supporting health. Assessing R/S means wading into these ambiguous spaces. It is imperative to know in what ways R/S may be helping and hurting, part of the problem and solution. In every specific case, several contextual factors need attention, including the nature of the presenting disorder (e.g., depression, anxiety, bipolar, schizophrenia, etc.), the R/S belief and/or practice, and the client’s community expectations of outcomes, and worldviews, especially as they relate to the origin and expression of psychological, spiritual, or religious distress. Clinicians and researchers have developed models over the years to address these complexities. Contemporary models of healthy vs. unhealthy R/S processes are partly indebted to the foundational work of Gordon Allport’s (1950) The Individual and His Religion, in which he differentiated a mature vs. immature religious sentiment. Mature religious sentiments are those that are rich, complex, flexible, and open to revision. In contrast, immature religious sentiments are those that are uncritical, exclusionary, self-centered, and prejudicial. While there is no foolproof strategy for handling every case where there is a potentially unhealthy R/S process taking place, here we briefly describe two assessment strategies we have found especially useful based on the work of Griffith and Griffith (2002) and Pargament (2011). The Spirituality of Relatedness For Griffith and Griffith (2002) there is a singular starting place for assessing the healthiness of a client’s R/S, and that is “Expressions of religious or spiritual experiences are harmful when they violate the relatedness on

114  Assessment and Case Formulation which spirituality is based” (p. 218). Like all concepts of unhealthy R/S, it is based upon their positive affirmation of what spirituality is. After all, how can anyone tell if they are holding a counterfeit dollar bill if they have never owned a real one? Their understanding of spirituality is “a commitment to choose, as the primary context for understanding and acting, one’s relatedness with all there is” (p. 15). As we have noted often in this book, relationship is a deeply R/S concept that is prized by most if not all R/S perspectives. Thus, their model prioritizes the care and well-being of the individual, unconditionally. They more clearly mapped out this maxim in Religion That Heals, Religion That Harms where Griffith (2010) described the sociobiological systems made up of Attachment, Peer Affiliation, Kin Recognition, Social Hierarchy, and Social Exchange that form the raw working material from which religious processes emerge. One way to explain the sheer power of religion (for good and ill) is to realize that it can activate all of these systems at once. For instance, it is not uncommon for members of a religious group to refer to one another as brother, sister, father, or mother, meaning it is capable of overriding our basic and stubborn instinct to recognize our family based upon blood bond only. It is a rare feat to be able to do this; few human experiences are capable of it. Even more rare, religion can do this while also activating attachment (God is a good/bad parent), peer cohesion (I have a group to belong to/excluded from), hierarchy (clergy are sacred authorities), and social reciprocity (the favor or kindness I show to my religious group should be respected and reciprocated). However, Griffith (2010) makes the case that if these sociobiological systems are not paired with what he calls themes of spirituality, including honoring the dignity of the individual, embracing compassion for all of life, and developing action-oriented states of emotion such as joy, hope, or gratitude, personal encounters with the sacred that evoke reflection, creativity, moral reasoning, and prioritizing the needs of the individual, then religion becomes constricted and can degenerate into sociobiological instincts of identity and ingroup–outgroup power dynamics. The great litmus test of the healthiness of a client’s R/S, then, is how it either promotes or destroys relatedness, especially with those who are considered Other or not part of one’s in-group. In other words, “Spirituality is person-centered religion” (Griffith, 2010, p. 30). The Pragmatic Approach The second way of assessing healthy and unhealthy R/S is based upon the pragmatic philosophy of William James. In Chapter 4, we discussed how quickly the dilemma can surface between assessing the relative health or unhealth of a client’s R/S process and potentially imposing the therapist’s beliefs and values onto the client when preparing to intervene. There we briefly touch on Pargament’s (2011) model which uses three criteria

Assessment and Case Formulation 115 (truth, pragmatic, and process). Here we expand upon this model in greater depth to illuminate its potential for assessment. First, the truth-based criterion refers to the right of each client to understand for themselves the truth about how their R/S is either healthy or unhealthy. As Pargament (2011) admits, this is the hardest criterion for therapists to assess. The reason for this is that the client’s understanding of the truth is often formed from within their own tradition based on personal R/S experiences, authoritative witnesses, faith leaders, and sacred texts, among others. These sacred sources are difficult to evaluate psychologically, as they originate from a different sphere of influence that psychological science is not always capable of addressing. For instance, psychological science has little to add regarding visions of founders of religions, ethical teachings, or rites and rituals. Moreover, when a clinician uses their social science training to evaluate the client’s truth, they can risk approaching their client’s tradition unilaterally. When clinicians privilege their social science perspective in making evaluations of the client’s R/S, this can come off as dismissive of the client’s tradition as a whole and will likely alienate them. Though therapists may be too limited to really assess this criterion with their clients, the client’s tradition is often of use in these cases as most R/S traditions have resources that are sophisticated enough and have confronted many of the challenges clients encounter in their journeys. So, while the truth-based criterion is difficult for therapists to assess for, it can become opportunities for clinicians to develop their competence through a deeper knowledge base of the client’s tradition. One way to address the challenge of adjudicating between what is healthy and unhealthy is to frame R/S pragmatically; that is, in terms of the functions it provides. Pargament (2011) points to James for guidance and what he calls the Pragmatic Criterion. For instance, about R/S, James (1902/1936) wrote, “Work is actually done upon our finite personality, for we are turned into new men, and consequences in the way of conduct follow in the natural world of our regenerative change” (p. 506). For James, the value of R/S is that it functions as a source of transformative change. The specific fruits of this change include “immediate luminousness . . . philosophical reasonableness, and moral helpfulness . . . the way in which it works on the whole” (James, 1902/1936, pp. 19, 20). These are three fruits that together represent pragmatic criteria for assessing the functioning of the whole and healthy person. Mapping these three fruits onto the three dimensions of the Ways Paradigm may also have pragmatic value for assessing R/S health from unhealth. For instance, James’s immediate luminousness might be seen as the fruit of compassionate presence exuded by healthy R/S ways of being. Just consider accounts of being in the presence of enlightened figures, such as the Dalai Lama or Desmond Tutu (Abrams, 2016). The fruit of philosophical reasonableness fits as a quality of R/S ways of understanding

116  Assessment and Case Formulation and thought that are grounded in wisdom. Parables and koans serve this end. And last, moral helpfulness is the fruit of action found in healthy ways of intervening and participating in the world. Exemplary R/S figures across the traditions serve moral goods of justice and peace. No set of criteria is perfect for adjudicating health across context, culture, and construct in our pluralistic age, but the practical value of James’s fruits and the Ways Paradigm offers a starting point. Finally, Pargament (2011) expanded upon James’s functional psychology by adding the process criteria of a well-integrated spirituality, which is “broad and deep, responsive to life’s situations, nurtured by the larger social context, capable of flexibility and continuity” as well as able to “encompass the full range of human potential and luminous enough to provide the individual with a powerful guiding vision” (p. 136). Whatever pragmatic criteria are applied to assess the whole of R/S life, James urges us to couple them with empathy: “We should treat them with tenderness and tolerance so long as they are not intolerant themselves” (James, 1902/1936, pp. 504–505).

Case Studies and Analyses Case 1 Hector, a cisgender heterosexual male, is a Hispanic American in his late 20s. Until the time of middle school, when his parents divorced, his family practiced Catholicism. He currently identifies as a nondenominational evangelical Christian because he prefers casual worship services over Catholic Mass. After a decade away, he returned to church after having married five years earlier. R/S are important to Hector, but “neglected” areas of his life. They play a role in his problems and their solutions, but he is unsure exactly how. After an affair and recent separation, he is having thoughts of selfcondemnation, religious guilt, and isolation from his religious community because of perceived rejection. His coping strategies oscillate between excessive drinking and believing the affair is part of God’s plan to help him to find a more fulfilling relationship elsewhere. He quotes part of a Bible passage, “All things work together for good, for those who are called according to his purpose” (Romans 8:28 ESV), to express his belief in a “bigger plan.” Hector also reports finding relief in what he learned about self-forgiveness from a six-week course he took on healing prayer at his church. For the first time during this class, he reports having an experience of resting in God’s loving presence, but he’s confused about how to trust God and make his own choices. Frustrated, he is waiting for God to show him his next move. Eventually, Hector discloses his parents’ divorce began with an affair. He is still angry at his father for “ruining and abandoning us for some other family.” In time, you also

Assessment and Case Formulation 117 learn that Hector is angry at God for his parents’ divorce, that he feels cursed by God, and is doubting his faith. He is deeply ashamed about repeating his father’s mistake. He is open, but not optimistic about the possibility of forgiveness. Applying the Ways assessment tool is done in two steps. First, the thoughts, feelings, and behaviors associated with the client’s challenges and resources are assessed. Hector’s struggles seem to include divine, intrapersonal, moral, doubt, and meaning struggles. His coping varies between religious beliefs and healing prayer. Having identified his struggles and coping resources, we can now apply the Ways Paradigm to outline the thoughts, feelings, and behaviors embedded in his struggles and resources (Table 5.2). In the second step, the assessment of challenges and resources is applied to inform the treatment formulation. Each dimension of the Ways assessment tool is used to identify essential areas worth exploring, including key R/S constructs. As seen in Table 5.2, ways of understanding identify that Hector appears to be using a combination of spiritual bypass (Welwood, 2000) and a deferring religious problem-solving style (Pargament, 2007) to minimize the painful reality of his responsibility for the separation and repeating his father’s mistake. Research has found that spiritual bypass involves a “defensive psychological posture cultivated by a tendency to privilege or exaggerate spiritual beliefs, emotions, or experiences over and against psychological needs, creating a means of avoiding

Table 5.2  The Ways Paradigm for Assessment of Client Hector Dimension of Ways Paradigm

Assessment of R/S Challenges

Assessment of R/S Role of R/S Resources in Treatment Formulation

Way of understanding (R/S thoughts and beliefs)

Self-condemnation; Knowledge of confused beliefs scripture; about God’s plan/ beliefs about role in his life moral values

Explore and assess God-concept, spiritual bypass, and R/S problem-solving style Way of being (R/S Guilt, shame, anger, Open to Explore and emotions and grief; feels cursed forgiveness, assess Godintuitions) by God experience of image and other loving presence obstacles to selfforgiveness Way of intervening Isolation from Healing prayer; Explore obstacles (R/S behaviors community; not attending to re-engaging and activities) relying on prayer church with church life community and use of healing prayer

118  Assessment and Case Formulation or bypassing difficult emotions or experiences” (Fox et al., 2017, p. 275) such as viewing his choice to pursue an extramarital relationship as “part of God’s plan.” Deferral, as a problem-solving style, involves deferring his freedom and decision-making responsibility to God, such as passively waiting for direction from God for his next move. There is also a selfdirective style (complete self-reliance), a collaborative style (human freedom combined with discerning direction from God) (Pargament, 1997), and surrender (human freedom focuses on letting go or surrendering some control, but not freedom) (Gorsuch, 1997). Hector may benefit to critically reflect on his understandings and beliefs about the meaning/s of God’s plan and how he discerns God’s direction for his life in relation to his sense of personal control. Ways of being indicate the R/S constructs of God-image (Rizzuto, 1979) and God-concept (Lawrence, 1997). Where God-image conveys one’s experiential understanding of God, typically informed by early connections with parental figures, God-concept conveys one’s cognitive understanding of God based on what one is taught. Hector’s conflict— feeling God’s loving presence but also feeling cursed—may parallel the abandonment by his father and care of his mother. Likewise, his ability to acknowledge God’s forgiveness may exceed his capacity to experience it emotionally. Last, ways of intervening point to the need to explore obstacles to Hector’s reliance on helpful coping resources, such as healing prayer and his church community. In sum, the trifocal lens of the Ways Paradigm suggests Hector may be poised for transformative coping in several areas. Case 2 Elissa, a Caucasian cisgender female heterosexual senior in her early 20s, comes to the university counseling center to address eating-related concerns and anxious feelings. The initial assessment reveals she was raised in a religiously unaffiliated family of high achievers in the Northwest. Both parents are law professors. Jokingly she tells of how when growing up, her family was more likely to go backpacking than to church. Her spiritual connection to nature is very important to her, which she accesses through trail running, gardening, and walking in nature. Though she is agnostic about the supernatural, she finds a doorway to something greater in the natural world. Many of her most significant moments of awe, peace, and gratitude have been outside in natural spaces. Elissa hopes to blend her degrees in ecology and urban planning to help bring sustainable farming practices into urban spaces. With graduation only months away, old habits are emerging at the thought of moving back home to the stressful environment of her highachieving family. She is noticing herself obsessing over calories, nutrition,

Assessment and Case Formulation 119 her appearance, and assignments, all related to the dreadful uncertainty of her still-unclear next steps. Exhausted by four years of high achieving, she has decided to defer graduate school for a year. She is considering working at a sustainable dirt farm out east to further her interest in ecology. As trust is built, she discloses she was molested several times by an older peer during elementary school, an experience she later learns her mother also had as a child. Regularly, she has nightmares of running from shadowy figures. She also harbors sentiments of being bad or corrupt, which she deals with by attending yoga or running on nearby trails. She is intrigued by some of the Buddhist practices introduced in yoga, such as metta (loving-kindness meditation), but troubled by her difficulty accepting self-compassion. Often these behaviors help, but sometimes they just leave her feeling exhausted without any prolonged relief for her anxiety and perfectionism. Moreover, when unable to keep up the routines used to defer her fear of imbalance, she becomes overwhelmed with failure. It becomes clear that Elissa’s pattern of tightly wound perfectionism is permeating and undermining her usual coping resources. The first step of assessment reveals that Elissa’s challenges and resources include moral and ultimate meaning struggles related to her abuse and existential anxiety over vocation. Her coping resources include practices of yoga, running, and gardening, experiences of connectedness to nature, knowledge about interdependent belonging with nature, and strivings to promote sustainable communities through revitalizing local farms. Table 5.3 outlines the thoughts, feelings, and behaviors relevant to Elissa’s treatment formulation. Here again, step two applies the Ways assessment tool to identify essential areas worth assessing, including key R/S constructs. As seen in Table 5.2, ways of understanding identify that Elissa may benefit from exploring constructs, such as spiritual transcendence and connectedness to nature. According to Reker (2003), spiritual transcendence is the meaningful integration of self, world, and a sacred force beyond oneself. Inner-connectedness, human compassion, and connectedness with nature are three factors comprising meaningful integration in Reker’s (2003) Spiritual Transcendence Scale. Nature connectedness is a subjective sense of one’s biophysical, cultural, and spiritual connections to nature. Importantly, the connection is not merely about human well-being, but the reciprocal interdependence one feels as part of an intrinsically valued earth. Both the Spiritual Transcendence Scale and Connectedness to Nature Scale (Mayer & Frantz, 2004) may help Elissa clarify some of the meaningful values and purpose embedded in her everyday experience of R/S. Ways of being raise the importance of metta or other practices of selfcompassion that may offer healing for patterns of perfectionism rooted in anxiety and trauma. For instance, according to Neff (2016), who draws

120  Assessment and Case Formulation Table 5.3  The Ways Paradigm for Assessment of Client Elissa Dimension of Ways Paradigm

Assessment of R/S Challenges

Assessment of R/S Resources

Role of R/S in Treatment Formulation

Way of understanding (R/S thoughts and beliefs)

Questioning purpose and meaning; moral perfectionism

Nature as source of selftranscendence, empathy, and connection

Way of being (R/S emotions and intuitions)

Feeling bad, corrupt, and imbalanced

Interest in metta; emotions of peace and awe in nature

Way of intervening (R/S behaviors and activities)

Self-care (yoga and running) activities hijacked by perfectionist and moral striving

Gardening, farming, yoga, running

Explore and assess nature connectedness, spiritual transcendence as sources to reframe perfectionism Explore and assess obstacles to selfcompassion and selfacceptance as resources for healing Explore healing potential of horticultural therapy, forest-bathing, and walkingmeditation

primarily from Buddhist writing of the Insight tradition (e.g., Brach, 2003; Kornfield, 1993; Salzberg, 1997), self-compassion simply refers to how one relates to oneself during moments of perceived failure, inadequacy, or personal suffering. The self-compassion scale (Neff, 2003) would help Elissa clarify her compassionate vs. uncompassionate treatment of self along three continuums of self-kindness vs. self-judgment, a sense of common humanity vs. isolation, and mindfulness vs. overidentification. Likewise, this would provide guidance on how to cultivate a self-compassionate frame of mind toward her perfectionism. Ways of intervening point to several ecotherapy coping practices able to compliment self-compassion and bring a gentler attitude to self-care, thereby balancing the striving attitude that creeps into her running. Helping Elissa explore practices she already enjoys and connecting them explicitly to self-care routines that ease perfectionism could be empowering. Case 3 Zadie is a first-generation biracial woman in her 40s. She identifies as cisgender and lesbian. Since her mother died two years ago, she has

Assessment and Case Formulation 121 experienced varying degrees of grief and anxiousness without abeyance. A void in her sense of identity and rootedness now exists. She understands her protracted grief as stemming from a frustrated yearning to maintain her connection to her mother and all that she symbolized; namely, the spiritual lineage of belonging to a people rooted in a shared sense of tradition and place. Growing up Zadie was exposed to an earthy, indigenous-infused Catholicism from her mother’s Kenyan roots as well as liberal Islam from her father, who grew up in Turkey. Raised in a large cosmopolitan city in the Northeast, she was able to participate in religious communities of both faiths. Despite the attitudes of openness and tolerance in her home, she struggled to find a place accepting of her whole self. Even in her college studies of world religions and women’s studies, interpersonal conflicts arose. Feminist literature critiqued her religious identity for being sexist and patriarchal, religious studies critiqued her sexual identity for being self-indulgent, and both lacked in their affirmation of what it means to be a biracial lesbian woman of color. Integrating the unique intersectionality of her identities proved complicated until she learned about Womanist spirituality (Williams & Wiggins, 2010). In Womanist spirituality she found a spiritual path, but since her mother’s death she began to feel drawn toward Kenyan spiritual practices as well. In particular, Zadie is piqued by practices of ancestor veneration and the porous line between the worlds of the living and the dead. Not having explored her mother’s connection to her deceased ancestors while she was alive is one of Zadie’s anguishing regrets. Step one indicates that Zadie’s challenges include an interrelated struggle between a loss of interpersonal support from her mother, intrapersonal doubt, and questions about how to rebuild the bridge to the lost spiritual meanings experienced since her mother’s death. In this sense, her prolonged and intense grief might be understood as a type of sacred loss (Pargament et al., 2005). On the resources side, gratitude abounds for the coping and support she finds in being with her Womanist spiritual community. Those relationships are validating and empowering of her whole self, including her striving to understand and meaningfully integrate this inchoate part related to her mother’s spiritual ancestry. As a teenager, she visited her mother’s extended family in Kenya. Even now, years later, this experience left the impression of a powerful love and sense of belonging to a self-transcending community. Without the immediate link her mother provided to this community, she feels cut off from transcendence. Table 5.4 outlines the thoughts, feelings, and behaviors relevant to Zadie’s treatment formulation. Salient areas and constructs worth assessing and exploring are identified in the second step of assessment, and include sacred loss, spiritual transcendence, and spiritual strivings. Ways of understanding link to constructs of sacred loss, spiritual transcendence, and spiritual strivings. Zadie may be experiencing a form of sacred loss. The bridge connecting

122  Assessment and Case Formulation Table 5.4  The Ways Paradigm for Assessment of Client Zadie Dimension of Ways Paradigm

Assessment of R/S Assessment of R/S Role of R/S Challenges Resources in Treatment Formulation

Knowledge from Intrapersonal Womanist struggles with and Kenyan meaning related spirituality to loss of home, place, and belonging symbolized by deceased mother Experiences of Way of being (R/S Interpersonal connection emotions and struggles related and acceptance intuitions) to grieving with mother’s loss of mother family (past) and feelings of and Womanist instability and community up-rootedness (present) Way of intervening Struggles with Being with (R/S behaviors finding steps Womanist and activities) to integrate spiritual Kenyan spiritual group; seeking identity practices of ancestor connection Way of understanding (R/S thoughts and beliefs)

Assess construct of sacred loss and explore ways to position spirituality as bridge to needs for spiritual transcendence Explore feelings related to sacred loss and spiritual striving

Explore behaviors related to striving to connect with mother’s Kenyan spirituality and ancestor connection

her to the transcendence and ultimacy of her Kenyan spiritual identity has been temporarily severed by the death of her mother. Losing her felt ability to connect to the sacred has powerful implications for functioning. When relationships imbued with sacred meaning are lost, so also may be resources for coping and well-being (Pargament et al., 2005). Sacred loss has been shown to associate with more negative affect, more negative physical symptoms, and heightened avoidance behavior and intrusive thoughts (Magyar, Pargament, & Mahoney, 2000; Pargament et al., 2005). Spiritual transcendence is a construct with varied meanings. Broadly stated, it concerns that which is greater or beyond the individual person. It may include the belief that there is a transcendent dimension to life (Elkins, 1998) or the perspective that an underlying unity pervades the diversity of nature (Piedmont, 1999). Depending on one’s spiritual orientation, spiritual transcendence may be understood vertically in terms of a Transcendent God or deity as well as horizontally in terms of a vast and interconnected, yet immanent Cosmos (Deal & MagyarRussell, 2018). In addition to Reker’s (2003) scale, Piedmont’s (1999)

Assessment and Case Formulation 123 Spiritual Transcendence Scale (Piedmont, 1999) is another tool for measuring Zadie’s sense of a larger meaning and connectedness to life beyond our mortal existence. These two constructs imply that treatment should explore Zadie’s understanding of how she might rebuild a bridge to the transcendent sense of ancestry and place linked to the loss of her mother. Ways of being should address the affective and experiential dimensions of Zadie’s loss of sacred meaning. This would involve supporting Zadie in attending to feelings of anxiety and up-rootedness while her bridge to the sacred is under development. Relationships in her spiritual community may provide emotional support during this time of spiritual uncertainty. Ways of being also highlight the construct of spiritual strivings, which are goals imbued by, and satisfying of, the need for ultimate meaning (Schnitker & Emmons, 2013). Whether aimed at “doing” (serving others) or “being” (self-acceptance), when strivings are sanctified, they are perceived as more meaningful, more supported by others, and more committed to others than less sanctified strivings (Emmons, 1999). They associate with greater well-being and less negative emotion (Tix & Frazier, 2005). People invest more time and energy into spiritual strivings and experience added well-being, meaning, purpose, and satisfaction than other self-focused and materialistic goals (Hart, 2007; Mahoney & Pargament, 2005). Supporting Zadie with actualizing her desire to connect to a self-transcending line of family ancestry and Kenyan spirituality would be imperative. Though ways of intervening do not identify any additional constructs, this dimension further supports the value of exploring ritual activities and/or practices that will actively build the spiritual connection after which Zadie is striving. Examples might include connecting with existing relatives on her mother’s side, seeking out a spiritual leader or shaman familiar with indigenous Kenyan spirituality, and seeking further education on these topics.

Conclusion To conclude, assessing the multi-variegated and pluralistic worlds of clients’ R/S is fraught with challenges. Therapists wonder how and where to begin, worry about offending clients, and may even deliberately avoid R/S because of unresolved conflicts and lack of familiarity with R/S worldviews. In this chapter, frameworks were introduced to mitigate these challenges. Tacit, implicit, and explicit dimensions were introduced as a stepping stone to address these preliminary challenges. Next, the ways paradigm assessment tool—guided by our inclusive working definition of R/S as what is transcendent, sacred, or beyond the ordinary—was introduced and applied to structure how therapists might assess a plurality of R/S worldviews as part of a treatment formulation. Two steps were outlined. First, the three dimensions of understanding, being, and intervening were applied to assess the thoughts, feelings, and behaviors

124  Assessment and Case Formulation associated with the client’s R/S challenges and resources. Second, this assessment was applied to inform the treatment formulation and planning. Key R/S constructs were discussed for each. The structure provided by the Ways assessment tool is an important step toward aiding therapists with the knowledge and confidence to assess the varieties of R/S, which for many clients are essential parts of the problems and solutions they bring to therapy.

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