Exploring Religion and Spirituality in Clinical Practice

Abstract

This article is a report on a study designed with experienced clinicians to explore the question of spirituality, religion and practice. Using eight focus groups from around the United States, the data provided support for the importance of theoretically grounded practitioners who have integrated spiritual and religious practices into their personal and professional lives. The participants' discussions provide strong support for exploring spirituality and religious beliefs in the context of the ways clients make meaning of life circumstances. An interesting finding is the importance of paying attention to the place of spirituality and religion in clinical practice.

KEYWORDS:

• spirituality
• religious beliefs
• clinical social work practice
• spiritually oriented mental health practitioners

INTRODUCTION

A review of the nascent research on religion and spirituality and its relationship to social work practice indicates a limited amount of scholarship on the definitions and inclusion of spirituality by clinical practitioners in their practice. Although research about direct social work practitioners is growing (Furman, Benson, Canda, & Grimwood, 2005; Sheridan, 2004), it is important to hear more from the voices of relationally based social workers and other mental health practitioners. Their focus on integrating the client's inner and outer worlds can enrich social work scholarship on religion and spirituality. And, as research on contemplative practices increases in disciplines related to physical and psychological care, it is also important that the profession of social work, which draws on scholarship from many of these disciplines, examine the ways religious and spiritual practices enable clients and clinicians to make meaning out of life crises and enhance healthy ways of coping and living.

Based on the growing literature on and interest in this topic, the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV; American Psychiatric Association, 1994) provided a new diagnostic category on the frequent occurrence of religious and spiritual issues in clinical practice: “This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution” (p. 685).

This recognition has supported and invited research and reflection on the place of religion and spirituality in the clinical work with the client. As a result, religious problems involving a person's conflicts over the beliefs, practices, rituals, and experiences related to a religious institution and spiritual problems involving distress associated with a person's relationship to a higher power or transcendent force that is not related to a religious organization have become important content for clinical practice (Lukoff, 1998). Therefore, attention to spiritual and religious assessment is important in diagnosis and in the ongoing clinical relationship.

Understanding and assessing the strengths and limitations of attending to religious and spiritual practices in clinical work is an important contribution that experienced clinicians bring to furthering our knowledge of and appreciation for this dynamic of practice. The current study contributes to the literature by using eight focus groups with experienced clinicians around the United States to explore the questions of spirituality and practice. It is the basic assumptions of the author that understanding the many ways a client and clinician make meaning of life's circumstances enhances practice and that religion and spirituality can mean different things to different clinicians. The research was conceptualized around the following five questions. First were “What is your definition of religion?” and “What is your definition of spirituality?” Intake questions and assessment tools are important in understanding the impact of attention to religion and spirituality in the clinical encounter. Therefore, another question asked participants to describe their intake and assessment process with regards to spiritual and religious assessment. Questions regarding religion or spirituality as a hindrance to clinical work and the explicit and implicit use of religion and spirituality in practice were also explored. It is important to note that this is the first in a series of articles based on the focus group data. The questions for data analyzed in this article are identified in the Method section.

LITERATURE REVIEW

Religion and Spirituality

The literature provides many definitions of religion and spirituality that inform their use by social workers and other mental health professionals in clinical practice. This review begins with the seminal work of Canda and Furman (2010) who in their most recent publication provide a comprehensive survey and analysis of the research and scholarship on religion and spirituality as it informs social work practice at the micro- and macrolevels. Their definitions are quite useful in placing attention to religious and spiritual contexts and issues in the purview of social work practice with individuals, groups, and communities. Griffith and Griffith (2002) provided excellent definitions of religion and spirituality for use in relationally based clinical social work. They enable the clinician to attend to religious and spiritual issues from the perspective of the client's inner and outer worlds. The focus is on the relationship with those variables that inform the ways the client makes meaning out of life events or circumstances. Lee, Ng, Leung, and Chan (2009) brought into clearer focus the usefulness of specifying nonreligious and Eastern conceptions of spirituality. This leads into the importance of mindfulness as a way of paying attention to the inner world of the client and the clinician as the latter attends to the clinical relationship. The significance of paying attention and bare attention surfaced in the focus group discussion. Epstein's (1995) work is included as a source for reflecting on the participants' responses.

Common Attributes of the Concept of Spirituality

Canda and Furman (2010) provided a summary of 12 commonly mentioned attributes of the concept of spirituality from the helping professions and religious studies:

1. An essential quality of a person that is inherently valuable, sacred, or immaterial. This is sometimes associated with beliefs about soul, spirit, vital energy, life force, consciousness, true self, or core nature.

2. An innate drive of persons to search for meaning.

3. A developmental process of searching and moving toward a sense of wholeness and connectedness in oneself and with others.

4. The contents of beliefs, values, moral frameworks, practices, and relationship with self and others, including ultimate reality, involved in this process.

5. Transpersonal levels of consciousness.

6. Particular experiences and states of consciousness of a profound, transpersonal, or sacred nature, such as out of body experiences, revelatory visions, sense of connection with spirits, communing with God, or cosmic consciousness.

7. Participation in spiritual support groups that may or may not be religious.

8. Engagement in particular beliefs and behaviors that support growth toward wholeness or contact with the sacred, such as prayer or meditation, in a religious or nonreligious context.

9. Central priorities that orient life toward what is considered ultimate, sacred, or transcendent.

10. Virtues that may arise from development of spirituality, such as compassion, love, sense of justice, forgiveness, and humility.

11. Qualities of well-being that may arise from spiritual development, and as resilience, joy, peace, contentment, and clear life purpose.

12. A holistic quality of the entire person in relationship, not reducible to parts, that includes yet transcends all the parts. Holistic awareness may emerge as one becomes aware of all one's aspects and relationships and works out a sense of integration and connectedness (p. 74).

These attributes led to Canda and Furman's further research and a comprehensive overview of the definitions of spirituality and religion in social work. In their surveys of social work practitioners who were drawn from the national social work organizations in four countries (the United States, the United Kingdom, Norway and Aotorea, New Zealand), Canda and Furman (2010) found that the practitioners were able to relate to the contrast and overlap between definitions of spirituality and religion that were most often presented in the literature (p. 68). They concluded that religion is “an institutionalized (i.e. systematic and organized) pattern of values, belief, symbols, behaviors, and experiences that involves spirituality, a community of adherents, transmission of traditions over time, and community support functions (e.g. organizational structure, material assistance, emotional support, or political advocacy) that are directly or indirectly related to spirituality” (p. 76). They also argued that spirituality is a process of human life and development focusing on the search for a sense of meaning, purpose, morality, and well-being. This process holds in context the relationship with oneself, other people, other beings, the universe, and ultimate reality however understood (e.g., in animistic, atheistic, nontheistic, polytheistic, theistic, or other way). It is oriented around centrally significant priorities and engages a sense of transcendence (experienced as deeply profound, sacred, or transpersonal) (p. 75).

Defining religion and spirituality in a relational context

In considering the significance of the relationship in clinical social work practice, Griffith and Griffith (2002) provided definitions of religion and spirituality that are most applicable to a study involving the exploration of spirituality and religion in clinical practice. According to them, “Religion represents a cultural codification of important spiritual metaphors, narratives, belief, rituals, social practices and forms of community among a particular people that provides methods for attaining spirituality, most often expressed in terms of a relationship with the God of that religion” (p. 17). On the other hand, spirituality is a commitment to choose, as the primary context for understanding and acting, one's relatedness with all that is. With this commitment, one attempts to stay focused on relationships between one's self and other people, one's physical environment, one's heritage and traditions, one's body, one's ancestors, and a Higher Power, or God. Spirituality places relationships at the center of awareness, whether they are relationships with the world or other people, or relationships with God or other nonmaterial beings (pp. 15–16).

Eastern definition of spirituality

The increased attention to nonreligious and Eastern spiritual perspectives invites the inclusion of more comprehensive definitions. Lee et al. (2009) defined spirituality as multidimensional. It entails cognitive, philosophical, experiential, emotional, and behavioral aspects. Their definition in the context of integrative social work includes religious as well as the nonreligious idiosyncratic beliefs and values of individual clients that constitute a source of personal aspiration:

Eastern conceptions of spirituality with philosophical roots in Buddhism and Daoism, include the capacity to endure the moment, to integrate different parts of “self” into a harmonious whole, to deepen connection with humankind and the universe, and to strive for higher goals such as compassion and loving kindness (p. 173).

Mindfulness

Research and scholarship on mindfulness has often been included in discussions regarding spirituality and meaning making. Such research enriches the discussion of relationally based practice. Mindfulness practices and principles have their origins in many contemplative and philosophical traditions; however, they can be easily adopted without adherence to a religious tradition (Melbourne Academic Mindfulness Interest Group, 2006). Mindfulness practices provide ways for purposefully paying attention to the present moment with an attitude of openness, nonjudgment, and acceptance (Hicks, 2009). According to Germer, Siegel, and Fulton (2005), mindfulness, as it relates to social work practice, can be defined as “the awareness that emerges through paying attention on purpose, in the present moment, and non judgmentally to the unfolding of experience moment to moment” (pp. 6–7). Mindfulness in relation to psychotherapy includes the components of awareness, present experience, and acceptance. Germer et al. (2005) viewed these distinct components as “irreducibly intertwined in the experience of mindfulness” (p. 7). Mindfulness and body-oriented work is useful in coping with stress and facilitating neurobiological changes in the brain for trauma victims (Kabat-Zinn, 1990; Steckler, 2006). Although the origins of mindfulness-based practices are in Buddhism, there are many secular adaptations and uses of mindfulness practices in stress management, mindfulness-based stress reduction, and psychotherapy (Benson, 1975; Kabat-Zinn, 1990; Linehan, 1993).

Paying attention and bare attention

In responding to religious and spiritual content in practice, the clinicians' heightened awareness of their own internal process and their clients' process is essential. It is in this therapeutic space where the clinician needs to pay attention to the dynamic process that opens one to explorations of what is sacred for the clinician and the client. As discussed by Epstein (1995), paying attention on purpose and bare attention are interrelated concepts that are important in clinical social work practice. Epstein spoke of a Buddhist imperative to pay attention on purpose in the following way: “Pay precise attention, moment by moment to exactly what you are experiencing, right now, separating out your reactions from the raw sensory events” (p. 110). He went on to define bare attention as allowing things to speak for themselves as if seen for the first time, distinguishing any reactions from the core event. Bare attention as defined by Epstein allows both the social worker and the client to fully focus on the present moment and to hold the past events and present experience in a way that enables the client to gain insight and engage in the process of meaning making, adaption, and change (p. 109).

Spiritual assessment

The literature on spiritual assessment is useful in understanding how clinicians can incorporate religious and spiritual strengths and needs into a comprehensive intake and assessment process. Spiritual assessment invites the social worker to be aware of what normative spiritual experiences are within the client's spiritual worldview. Sometimes the negative effects of religious experiences or understandings must be understood for clinical work to be effective (Northcut, 2000). When the social worker is unsure, consultation with religious leaders from the client's tradition is important in understanding the appropriate expressions of spirituality and ways of making meaning within the client's religious tradition (Hodge, 2004).

Several techniques or tools, such as life reviews, spiritual genealogies, religious or spiritual histories, life maps, and genograms from spiritual perspectives, can assess the positive or negative implications of the client's spiritual and/or religious practices. The tools are useful across theoretical perspectives on human growth and development. Life reviews provide opportunities to resolve earlier conflicts with significant others and God. In addition to the life review, a spiritual genealogy that charts a client's spiritual family tree can add to the life review for ongoing work. Religious or spiritual histories allow exploration of the religious traditions of primary caregivers, one's spiritual beliefs and practices, along with the degree of integration within the faith community. Spiritual turning points that are identified in client histories are moments that the clinician and client may identify in initial assessments or throughout therapy. They are useful in understanding an individual's belief regarding the power of external and internal forces in life (Fiori, Hays, & Meador, 2004) whereas spiritual life maps provide opportunities for a pictorial depiction of one's spiritual journey. Genograms allow for the exploration of the relational dimensions of spirituality. They can highlight spiritual resources, significant relationships, and other spiritually based information that may be significant for the assessment and intervention phases of social work with individuals and families (Bullis, 1996; Dunn & Dawes, 1999; Hodge, 2001, 2003a, 2003b). One can adapt these techniques or tools to fit most practice intervention strategies.

METHOD

Overview

This qualitative research was designed to gain clinicians' perspectives of and insights into religion and spirituality in the context of their practice. A graduate student in social work was the facilitator for four of the focus groups; the author facilitated the other four groups. However, the author was present and took field notes at three of the groups lead by the graduate student. The multisite focus groups were designed to reflect regional perspectives on the topic. Six regions of the United States were identified with two groups in two regions. They were Western Massachusetts (Northampton); the Bay Area of Northern California (Oakland and San Francisco); Albuquerque, New Mexico; Atlanta, Georgia; Chicago, Illinois; Colorado (Boulder and Denver). The selection of two cities in two regions was predicated on an assumption that participants in those regions would be inclined to participate if they did not have to travel the distance between the cities.

The focus group interview guide included participant introductions and questions that explored (or were developed from) the following four themes: definition of religion and spirituality, intake and assessment, explicit and implicit use of religion, and potential negative and positive impacts of attending to religious and/or spiritual issues. There was a final question regarding anything that had not been covered; this lead to discussion of paying attention in clinical practice. A report of the findings on the explicit and implicit use of religion and potential negative and positive impacts of attending to religious and/or spiritual issues will be discussed in future articles. Below are the questions as well as one example of a follow-up probe for each question.

• Question 1: What is the operational definition of religion and spirituality for clinical practitioners? (Probe: How is religion and spirituality different for you in your professional life and your personal life?)

• Question 2: Do they include spirituality and religious themes in their intake and assessment of clients? (Probe: Give an example where this is important for a client.)

• Question 3: Are there explicit and/or implicit uses of religion and spiritual content in clinical practice? (Probe: Do you use ritual, prayer, or meditation in the clinical session?)

• Question 4: What are the potential risks or benefits of attending to religious and/or spiritual issues in clinical practice? (Probe: What are the transference and or countertransference concerns?) Question 4 was often reframed by participants that one needed to focus on the clients' strengths and vulnerabilities before identifying risks and benefits. It was in discussing this question that the discussion in most groups shifted to paying attention to the meanings expressed by the clients before moving on to a general discussion of risks or benefits.

Although no set time was allotted for each question, we balanced time for participant sharing, follow-up on common themes, and responses to each question.

Data Analysis

The analysis of data used a pragmatic approach to grounded theory that recognizes the research questions and their intent. Here the study of the phenomenon leads to theoretical formulations that are discovered, developed, and verified through systematic data collection and analysis (Strauss & Corbin, 1990). This iterative process resulted in the development of in vivo codes that lead to particularly colorful quotations or sound bites that encapsulated a common or shared perspective that requested further explanation from the researcher (Barbour, 2007, pp. 120–121).

Sampling

The participants were recruited via e-mail and word of mouth from the Smith College School for Social Work alumni affairs office, referrals from alumni, the Smith network of clinical practitioners, and the Naropa University alumni. The e-mail recruitment letter asked the primary study question: Can spirituality and religion have a place in the clinical relationship? It defined the sample as clinicians (doctoral-level psychologists, master's-level clinicians, social workers, pastoral counselors, and family therapists) who have been licensed for at least 5 years. There was no compensation for participation in the focus groups. The goal was to have a minimum of five participants for each focus group. However, one group had only two participants whereas the others ranged from three to nine participants.

Nature of Participation

Participants were asked to complete a demographic questionnaire and take part in a 2-hour, audio-taped focus group session. The focus groups took place on college campuses and at agencies, community centers, and hotel conference rooms. Participants were given informed consent forms and were instructed to disguise any client examples they provided during the focus group session. They were also informed that no identifying information would be included in any publications or presentations. The study procedures, instruments, and forms were approved by Smith College School for Social Work's Human Subject Review Committee.

Process of Data Analysis

The focus groups' audiotapes were transcribed and checked by the author for accuracy. Each participant's comments were reviewed to decide whether any one comment addressed more than one substantive issue or theme. If so, the comments were cut and pasted under the identified theme. Field notes and behavioral observations were included in the analysis for seven of the focus group sessions.

An inductive approach was used in analyzing the data. After the author reviewed the comments several times, categories began to emerge that enabled her to begin a formulation of the participants' responses. Another researcher then reviewed the coding process, themes, and comparisons for agreements and disagreements. Where there was disagreement, the author and researcher engaged in dialogue and came to consensus regarding the coding. Direct quotations were used to highlight and ground the findings and their interpretation meaning in relation to the study question and the literature (Barbour, 2007; Faulkner & Faulkner 2009; Fern, 2001).

FINDINGS

Demographics

There were 40 participants, 16 (40%) men and 24 (60%) women. Their ages ranged from 46 to 72 with a mean of 53 years. The racial breakdown was 30 (70%) White, 4 (10%) African Americans, 2 (5%) Hispanics, 2 (5%) Asian, 1 (2.5%) biracial, and 1 (2.5%) unknown. The range in number of years licensed was 2 to 35 with a mean of 17. Three participants only had 2 years postlicense experience. However, the author decided to allow them to stay for the focus groups. For these three participants, responses to other demographic questions and to the focus group questions were within the range of responses from the other participants. Degrees obtained by the participants were 27 MSWs, 4 MSWs and 4 PhDs, 2 with MSWs and MDiv.s, and 3 MDs.

Theoretical orientations

Fifteen participants reported being trained in the following theoretical orientations: psychodynamic (n = 10) (67%), psychoanalytic (n = 3) (20%), and psychoanalytic psychotherapy (n = 2) (13%). The other 25 participants indicated combinations of two or more theoretical orientations that spanned an extensive range of possibilities. Thirteen (52%) of the 25 included psychodynamic with one or more additional theoretical orientations. As a result, the majority (n = 33) (82%) included psychodynamic psychoanalytic in their theoretical orientation.

Predominant Composition of Populations Served

Although the participants served multiple racial groups, the primary populations served included White (n = 16), African American (n = 9), Hispanic (n = 8), Asian (n = 2), and Native American (n = 2). Specific religious groups listed by clinicians included Christian (n = 10), Jewish (n = 3), Buddhist (n = 2), and Neopagan (n = 2). It is important to note that participants were not exclusively serving one racial or religious group.

The participants' practice included work primarily with individuals (n = 22), couples (n = 14), families (n = 5), adolescents (n = 4), and children (n = 2). However, several participants also reported working with individuals with different social identities; they included sexual/gender/lifestyle minorities, geriatric, young adult males, men, college students, Middle Eastern, Alcoholics Anonymous, HIV, low social economic status (LSES), multiethnic, and veteran. Populations-served data are missing for six participants in Western Massachusetts.

Practice Settings

The majority of the participants were in private practice (n = 12) (30%), agency and private practice (n = 12) (30%), or agency-based practice (n = 11) (27.5%). Two (5%) participants were in academic settings and private practice, one (2.5%) was in a hospital setting and private practice, one (2.5%) was in an academic setting, and one (2.5%) was in private practice and a parish setting.

When asked about the types of contemplative or spiritual practices included in their practice, the participants gave multiple responses. They included the following: 15 indicated contemplative. 22 indicated meditation. 28 indicated mindfulness. 13 indicated prayer, 16 indicated meaningfulness, 13 indicated story telling, 21 indicated journaling, 9 indicated art, 10 indicated somatic/body-oriented work, 10 indicated Eye Movement Desensitization and Reprocessing (EMDR), and 10 indicated other.

Twenty-eight participants had additional specialized training or certificates in clinical theory and practice or religious or spiritual practices. A sample of their experiences that enhanced their primary orientations included theology, EMDR, cognitive therapy, and mindfulness-based stress reduction.

Personal Spiritual or Religious Practices and Religious Affiliations

A comparison of the participants' personal spiritual practices and religious affiliations was undertaken to explore how their personal practices and affiliations might affect their professional practice. The findings of this comparison are described below.

Nineteen (48%) participants reported that their personal spiritual or religious practice was firmly connected to their religious affiliation. Twelve (30%) identified a specific religious affiliation though their spiritual practices crossed into other religious practices; nine (22%) identified with specific spiritual practices but no religious affiliation. It is important to note that those who adhered to a traditional affiliation and those who did not all used a range of spiritual practices. Among the practices and affiliations listed, there was great variation in religious and spiritual traditions including traditional and nontraditional organized religion to no formal established religious affiliation. One half the participants included mindfulness as one of in their spiritual practices; meditation, prayer, and body-oriented work were also well represented in their work with clients.

As a group, the participants' spiritual or religious practices are not confined to the traditional rituals of their religious affiliation. This is an important finding when considering their responses to the types of contemplative or spiritual practices included in their professional practice. Their responses indicate that practices from other religious traditions are clearly part of the participants' personal and professional practice.

Participants' Definitions of Religion and Spirituality

Because Canda and Furman's (2010) analysis of the literature on attributes provides a useful framework for exploring the different parts of definitions of religion and spirituality, the author used these attributes to organize the following section and identify the connections of the participants' responses to the questions of defining religion and spirituality.

Attributes of the Concept of Spirituality

It is important to note that Canda and Furman's (2010) publication occurred after data collection was completed for the current study. Their attributes of the concept of spirituality would have provided an interesting question to explore with participants. Despite the timing, the author found that elements of 5 of the 12 attributes closely correspond to a majority of the participants' responses. Statements of each of the five attributes are illustrated with a typical participant response to the question regarding defining religion and spirituality.

• Attribute 1: “An essential quality of a person that is inherently valuable, sacred, or immaterial. This is sometimes associated with beliefs about soul, spirit, vital energy, life force, consciousness, true self, or core nature” (p. 74).

A participant reported, “For myself, it (spirituality) is the way I live my life apart from whatever religious practices that I might engage in. So spirituality is part of my identity.”

• Attribute 5: “Transpersonal levels of consciousness” (p. 74).

A participant explained, “Spirituality is sort (of) an innate impulse or element in the human psyche and it's just natural … it's just there, but it sort of moves us toward … it sort of gives us an impulse or urge toward something larger … the transpersonal or the God or the higher power … whatever that may be.”

• Attribute 6: “Particular experiences and states of consciousness of a profound, transpersonal or sacred nature, such as out of body experiences, revelatory visions, sense of connection with spirits, communing with God, or cosmic consciousness” (p. 74).

One participant stated,

The word spiritual has something to do with the flow of the spirit through us. It's a sense of having an understanding within yourself of how you relate to your environment and to other people … there was a sense of spirituality that came from my great grandmother who was a Curandera … and there were a lot of beliefs beyond just what you would call traditional religion and the way she practiced. Spirituality tends to be my individual expression of my connection with the greater … the greater powers in the universe … the healing powers, whether that is expressed through a religious group or community, or individually focused in terms of my own connection with the interconnected web, or my part of the healing powers of the universe.

• Attribute 8: “Engagement in particular beliefs and behaviors that support growth toward wholeness or contact with the sacred, such as prayer or meditation, in a religious or nonreligious context” (p. 74).

One participant said,

I define it (religion) as kind of an organized philosophy. That people come together and practice in that sense of community that helps teach morals. Spirituality is defined as relatedness sort of with yourself, with other people, with all cultures, people in all kinds of places and then whatever it is that both connects you to something bigger than yourself as well as maybe even your fears around what is evil.

• Attribute 11: “Qualities of well-being that may arise from spiritual development and as resilience, joy, peace, contentment, and clear life purpose” (p. 74).

A participant noted, “When I think of spirituality, I think of basic principles of living that enable me to touch the deeper parts of myself, and ultimately experience those transcendence experiences that bring meaning and quality of life.”

Defining religion and spirituality in a relational context

When exploring the definitions of religion and spirituality, the participants clearly saw the importance of defining those concepts in relation to each other (Griffith & Griffith, 2002, pp. 15–17). For religion, the majority spoke of belief, rituals, practices, and a form of community expressed in terms of a relationship with a God or several deities. On the other hand, the participants' definitions of spirituality, in comparison and independent of religion, spoke of relationships between self and nature, other persons, transcendent others, and the search for meaning, compassion, and well-being. The participants' perspectives also supported the centrality of relationship as they spoke about spirituality and clinical practice.

One participant's discussion on spirituality and religion eloquently captures the sentiments of the majority of the other participants:

Spirituality is a personal internal relationship to the world … to the higher power—however you might want to conceive it—and my position in it … and it also goes inward to my relationship to my internal self. And I think religion as being organized practices and ceremonies in a mosque, or a church, or a temple, or some real organization … and they aren't necessarily separate, but you can be very religious and not very spiritual.

Intake and Assessment

The participants were asked to describe their intake and assessment process with regards to the religious and/or spiritual problems presented in therapy, the tools they used in their spiritual/religious assessment or treatment process, and the use of mindfulness and/or contemplative practices.

As for religious and/or spiritual problems, the major ones cited by the participants involved emancipation, guilt, struggle to regain faith, how to understand or make meaning of life's crises, and forgiveness. Often these were the result of particular events such as sexual and/or domestic abuse, loss of loved ones, loss of career, or perceived violations of a particular religion's teachings. For example, one participant reported, “I work with college age populations. Knowing their families of origin, and what their religious practices were—or were not—and my students' reaction to that … that's a part of the emancipation process.” Another recalled a client who struggled with addiction and guilt. He had been raised Catholic and had lost a son in an accident. The participant continued, “At some point we did a lot of wrestling with the Catholic faith … and his beliefs … because there was a part of him that was using his guilt to self-sabotage and blame himself for his two-year-old's accidental drowning.”

Other participants related the particular struggles of girls or women. One reported the following:

I work with a lot of Irish Catholic women who've had abortions … who've never told anyone … never been able to forgive themselves.… There has been so much shame attached to it. But then, (I used the clinical relationship) to help them explore maybe even a different understanding of God or a different understanding of their belief system with the Catholic Church.

When discussing assessment tools or outside resources, the participants stated that they rarely used specific spiritual assessment tools or consultation with religious leaders. They relied on their basic clinical assessment and interviewing skills to determine the best course of treatment in light of the presenting problems and the clients' internal and external resources. Thus the majority explored with clients the meaning of particular events that may have had an impact on their psychosocial development or presenting issues.

Examples of basic clinical practice focusing on spiritual practices or beliefs included asking clients about their spiritual practices or belief and waiting until the client mentions it directly to explore its meaning in their lives. Another example is being specific about what the client believes. Not just asking what faith or denomination they are but asking what that means in their daily living and decisions. Some participants have included the spiritual dimension in the bio-psycho-social assessment.

Mindfulness and Contemplative Practices

Mindfulness brings attention to whatever arises in the present moment. It increases the clinician's use of the clinical process and their awareness of their own reaction within the present moment. There are a range of other contemplative practices including silence, pilgrimages, ceremonies, yoga, art, journaling, prayer, and body awareness that can be useful in exploring the spiritual and/or religious meanings in the client's life.

The following quotations exemplify the range of religious and/or spiritual problems presented in therapy, the tools or techniques used in the assessment or treatment process, and the use of mindfulness and/or contemplative practices. The findings on intake and assessment include examples of obtaining a spiritual history, using techniques of mindfulness and yoga, and three examples of paying attention to clients' use of prayer.

“While obtaining a spiritual history the client presents his near-death experience as his ‘come to Jesus moment’ … but Jesus came to him … talked to him … and like said, ‘Who the hell do you think you are not believing in me”. There were examples of clinicians using techniques of mindfulness and yoga to understand the spiritual connections with client issues. For example,

A man who is struggling to have a meaningful relationship in his life … and is very much up in his head trying to figure out what he's supposed to say to women when he meets them. And doing a little history … where this comes out of is some rather abusive stuff that happened in his childhood. He has kind of just shut down his feelings … and what I've found really works for him—and some other people I've worked with in a similar situation. I don't use the word mindfulness, but just inviting him to go into a quiet internal space … and from that space he's a lot more able to access the mind/body/ kind of feelings and emotions … and he's found it useful. And he's gotten involved in yoga which does the same thing for him. I mean, it's a place where he doesn't have to be analytical … he's really becoming conscious of his body and his feelings on a very direct level … and to me that's spiritual work.

Paying attention to the clients' use of prayer enables the clinician to understand the resources available to the client that increase coping skills and ways to make meaning out of life's crises. Participants stated that enabling clients to look at their prayer and use it to connect via a spiritual process with a “deeper part of themselves to whatever or whoever they need to be in a meaningful way … and to act on it.” It moves the clinician's ability to understand the internal resources born of spiritual practices and religious beliefs to a deeper level in the therapy. “Listening to how they pray is a short cut to object relations.” The following quote provides a nuanced perspective on prayer as a resource for meaning making.

In an interview with a foster grandmother who is raising a severely multiple disabled child … when asked how she does it, she said, ‘Well, I pray.’ In describing her internal strengths she said, ‘There's a sort of a spirit I have … that not only allows me to be patient with this little boy, because he can be a behavior problem also.’ He has very limited speech, so it's hard to get from him what he's feeling and what his needs are … so she said, ‘It's a spirit that allows me to be patient with this little boy. It's a spirit that allows me to just keep on going even though we only have limited resources.’

Spiritual assessment quotes from participants demonstrates how one views good clinical practice that involves a heightened awareness of spirituality and religion as strengths or areas needing attention.

Paying Attention

This final section represents the majority of the participants' perspectives on paying attention and listening. Paying attention became an important theme in most of the focus groups. It was the predominant response to the question at the end of the session that asked if there was anything the participants would like to add. It invited the author to look at this very important factor in good clinical practice. In these examples, participants share the wisdom of their practice experience and invite us to understand the underlying dynamic and the issues of countertransference and transference. Most important, one can see their personal spiritual practice and profession practice at play in the dynamics of paying full attention to the client, the clinical relationship, and themselves. The first participant speaks to how to listen for the God representation in the clinical encounter. The comment supports an assumption that object relations provide a sound theoretical orientation for exploring the sacred in therapy (Jacobs, 2010). The participant said,

I think listening for … from a psychodynamic standpoint is … their God, a loving soothing nurturing God or a burnt object … you know how they are internalizing that. So I'm just listening for it, in a way, as a kind of strength … as something that I can maybe be able to use if needed, I think, or if they go there. I just listen for it to use as a coping and also just to understand what their object world is like … what that essence is for them. Is it punitive or is it nurturing? Is it forgiving or not? It gives me a sense of their internal world.

Another participant explained the importance of meditation or prayer practice for the clinician. Listening and paying attention are foundational techniques in meditation, mindfulness, and contemplative prayer. As the clinician attends to her inner world, skills of deep focused listening and awareness of countertransference issues will increase. In addition to enhance basic clinical practice skills, this will enable the clinician to more skillfully focus on the meaning of spiritual and religious issues for the client. The demographic data finds that the majority of the participants maintains a personal spiritual practice and provides a range of contemplative practice opportunities for their clients. These practices are essential in developing strong skills in listening and paying attention. The participant said,

I have no idea how anyone does this work without something spiritual … or a meditation or prayer practice … because everything I know about how to sit here and how to hold the kind of attention I need to hold … I've learned from that practice. I think of my professional work as a spiritual practice. It's so a part of how I approach each day and it's so present to me each day that of course it comes up in questioning and in conversations with clients … what meanings religion and spirituality have for them.

Finally, the third participant discussed the importance of clinical supervisors providing contemplative practices for supervisees and other staff in clinic and hospital settings. Like many of the other participants, there was an experienced of positive institutional support. As this participant explained,

The work with mindfulness is more meditative. It's more of a let's take a moment to just kind of be here, to focus on our breathing and to focus on what's in the moment here from a sensory standpoint as a way of calming or centering. I think of that as part of the spiritual practice that I certainly bring in to the hospital work on a regular basis … including with my staff. It's not just the clinical work with patients, but clinical work in supervision and consultation. It is a critical piece of the work that I do, being able to help staff kind of regroup when they're feeling incredibly stressed or in tears because of something that's happened in the unit … a really traumatic death or a difficult child protective service case or just it's really tough work. So part of my work is just kind of being there for them … let's take a breath let's regroup, let's gather in to ourselves.

Paying attention from the space of the clinician's personal and professional life was highlighted in the proceeding quotation. The importance of the participants contemplative practices were an assumption of their willingness to participate in the study and their experiences of attending to spiritual and religious issues in their practice. While not a direct question, the rich focus group responses regarding listening and paying attention to the clients invited their inclusion in the study report. Epstein (1995) spoke to paying attention and listening nonjudgmentally to the client and to oneself. Three participants provide unique perspectives on this stance. The first one spoke of attending by being present: “Attending by being present when my client says, ‘there must not be a God to make me feel like this.’ That's attending … that he could say that in the session. I'm not going to go into ‘yes’ or ‘no.’ When he talks, he talks. That is attending.”

The second participant discussed moving from an authenticity place of appreciating one's self and the client:

I have a belief that it's a kind of a goal … kind of from a Buber's perspective around “I and thou” and that is the fully appreciating the other person, the authenticity of the other person and coming from an authentic place yourself as a therapist … is a kind of spiritual frame, I guess, or experience kind of moving from a transference/countertransference to an “I and thou” relationship.

Drawing on Winnicott's ideas of transitional space, the third participant spoke of spaciousness. Here there is the opportunity to engage the religious or spiritual concerns in the context of object relations theory (Jacobs, 2010). According to this participant,

“Generous spaciousness” … as a combination of the idea of potential space that Winnicott brings. If I like J's idea about if we are lucky enough to love and be loved by our clients … that it gives that spaciousness. It opens our hearts and so sometimes I see this spaciousness as within us so that we can tolerate and hold a lot. You can talk about it more as opening the space in the client's mind really if you can have them breathe some fresh air.

DISCUSSION

The findings of the current study support the belief that attending to religious and spiritual practices in clinical work is an important contribution that experienced clinicians bring to furthering our knowledge and appreciation this dynamic of practice (Canda & Furman, 2010; Epstein, 1995; Lee et al., 2009; Lukoff, 1998; Northcut, 2000; Sheridan, 2004). Specifically, the findings provide valuable insights from the participants in the focus groups on the fluidity of definitions as well as on the importance of theoretical orientation, of experience in understanding the place of religion and spirituality in intake and assessment, and of paying attention in clinical practice.

The Fluidity of Definitions

One can conclude that there is an openness and fluidity of approaches to multiple ways of finding religious and spiritual support and meanings in the lives of the participants that can translate into an openness in their clinical practice with clients who may be within a specific tradition or searching for a spiritual connection. This reflects the dynamic stance of the participants in which being with clients in the space of a clinical relationship leads to tentatively holding formulations as the process unfolds. Connecting the definitions to the attributes of the concept of spirituality affords a way to view their different dimensions in the context of existing literature and research. Embedded in the definitions were many of the universal perspectives involving religion as structured dogma around inclusion or exclusion based on accepted a specific set of beliefs. Spirituality is focused more in the individual's practices and connection with self and others in relationships that give personal ways of making meaning of life circumstances. The boundaries in definitions between the two are quite fluid when considering the impact on the client's inner world.

Many of the attributes the participants identified were supported in research by Canda and Furman (2010). Identifying the attributes of the concept of spirituality with the findings from the study offered an analysis that was only available after the study was completed. It points to an interesting opportunity in developing clinical social work education competencies of relevance to spirituality and continuing education courses. Such a development may contribute to contribute to ongoing assessment and clinical use of the DSM-IV diagnostic category on religious and spiritual issues in clinical practice.

The Importance of Theoretical Orientations

Most of participants are educated in a psychodynamic perspective and thus the relationally oriented definitions of religion and spirituality as provided by Griffith and Griffith (2002) have a synchronicity with their articulation of definitions. This is important for those clinicians who have integrated relationally based theories into their practice.

During the focus group sessions, there were moments of silence and reflection that gave voice to the complexities of the questions. It is clear that the psychodynamic education and training within the group gave them the theoretical foundation from which to wisely explore their personal and professional experience of spirituality.

The Importance of Experience in Understanding the Place of Religion and Spirituality in Practice

Allowing the focus of clinical attention to include spiritual and religious problems or strengths requires knowledgeable clinical practitioners. The clinical practitioners need to have a clear sense of how spirituality and religion fit within their therapeutic framework and a willingness to allow the clients' meaning of this strength or problem to unfold in the clinical relationship. Given the average age (53) and the average time of licensure (17 years) of the participants in the current study, it is obvious that they were a senior group of clinical practitioners. However, the clinically sophisticated discussion of spiritual intakes and assessments and of potentially negative religious experiences also provide examples of their clinical expertise and contemplative wisdom. Furthermore, their awareness of paying attention, listening, and being mindful are reflected in their responses about their own spiritual practice and the contemplative and spiritual practices they make available to clients.

Over the years, the participants have also added clinically related educational and contemplative practice experiences from other theoretical perspectives. Workshops and certificate training represented the broadest definitions of mind, body, and spirit work. They were quite comfortable with the inclusion of other perspectives while being clear about their grounding in psychodynamic practice. Their personal spiritual practices were important to their professional lives as reflected in the range of contemplative and spiritual practices they made available to clients.

The Importance of Paying Attention in Clinical Practice

Paying attention is at the heart of excellence in clinical practice. Yet, with the demands for tightly scheduling clinical hours, many clinicians find that the time spent on meditation, mindfulness, or other contemplative practices that enhance paying attention are sometimes cut short. Without attention to one's personal contemplative practice and the insight through supervision that comes in helping the clinician understand the countertransference issues, the capacity to pay full attention is sometimes limited. To be able to practice bare attention allowing events, feelings, circumstances, and religious and spiritual history to speak in the clinical relationship is a gift from paying attention.

CONCLUSION

The rationale for designing focus groups around the country was to include a diverse sample in terms of geography, gender, race and ethnicity, spiritual practices, and religious affiliation in exploring spiritual and religious concerns and strengths in clinical practice. However, the limitations of the study involved the size of three focus groups that were under the desired number of five participants. Also the majority of the participants were alumni of the Smith College School for Social Work. This made for homogenous theoretical orientations that though richly positioned for depth of discussion may have limited the range of theoretical formulations informing practice. The author suspects that the nature of a self-selected group drew participants who had a commitment to the inclusion of spirituality in clinical work. Future research could probe more deeply into the clinical work for the ways clinicians manage the relationship that invites attending to the spiritual content over time.

For each group, there was the delight in their having the opportunity to be with other clinicians who may have had less or more support for discussing the complications of addressing these issues. For some, the experience of the focus group provided moments of being a consultation group as we probed together for the underlying meanings in response to questions. The importance of an experienced sample of clinical practitioners allows one to know how they see the clinical boundaries while knowing the permeability of all boundaries. They are uniquely able to hold and pay attention to that in the clinical relationship.

For the field of clinical social work that holds to the importance of grounding in theory, based in the clinical relationship and responsive to cultural and spiritual contexts, this focus group research gives insight into the wisdom of clinical practitioners who have included spirituality and contemplative practices in their personal and professional lives. They provide a generous spaciousness to their clients and to all of us in their invitation to explore spirituality and religious beliefs in the context of practice. This research expands our understanding of the capacity to bring spiritual and religion experiences and concerns fully into the bio-psycho-social-spiritual perspective. Many clinical social workers have a commitment to relationally based practice that is grounded in theory and culturally responsive. With the inclusion of spirituality and religious beliefs in this commitment, we expand the definition of the relationship in practice and the cultural responsiveness. The relationship becomes open to the transcendent other, ancestors, and all of creation as mediated through the clients' cultural and spiritual lens. We become more aware of the issues of countertransference as clinicians explore and respond to their own spirituality and religion. Experienced clinicians bring an important voice and wisdom to our understanding of the strengths and limitations of attending to religious and spiritual practices in clinical work. The careful attention to the spiritual and religious content in the lives of clients' demands of the clinician practice wisdom and spiritual practice. This article is an opportunity for clinical social work education to listen to clinical practitioners and to pay attention to the complexity and richness of attending to the spiritual as strength in reflecting with the client on the meaning of life's circumstances.

ACKNOWLEDGEMENT

This research was made possible through the generous support of Caroline Woods, M.S.W. '98, and with the able assistance of Julia Gallichio, M.S.W. '09, graduate student and research assistant, the development of the research design and data collection from four focus groups were effectively implemented. I am grateful for the study participants who so generously gave of their time and wisdom.