When pitcher Zack Greinke left the Kansas City Royals during spring training in 2006, it wasn’t because of a sprain, a break or a torn muscle. Something less visible was threatening his promising baseball career: clinical depression and social anxiety disorder.

With the help of counseling, Greinke was able to work through the issues that plagued him and returned to the mound a few months later. Fast-forward three years, and Greinke is now a star pitcher who has appeared on the cover of Sports Illustrated.

Greinke’s story of recovery from social anxiety disorder is particularly amazing when you consider that each time he reports for work, he’s performing in front of thousands of fans. But he’s far from the only person struggling with anxiety. Anxiety disorders are the most common mental illness in the nation, affecting 40 million adults or 18 percent of the adult population.

Social anxiety disorder is characterized by an intense fear of social or performance situations and the feeling that others are scrutinizing you, often leading people who struggle with the disorder to avoid being with others. When those situations can’t be avoided, these individuals are consumed by how others are viewing them.

“People with social anxiety often have this magical kind of thinking that they know what the other person is thinking about them — and of course, it’s negative,” says Stephnie Thomas, a member of the American Counseling Association who has worked at the Anxiety and Stress Disorders Institute of Maryland in Towson for 12 years. “Most of us have periods of shyness, but (social anxiety goes) beyond shyness.”

Blushing, feeling hot in the face, sweaty palms, a racing heartbeat — all can accompany social anxiety, Thomas says. People who struggle with the disorder are consumed by the feeling of needing to say or do the right exact thing so that people will like them. “Remember those awkward adolescent years where you felt like you had two left feet?” Thomas asks. “Social anxiety disorder is kind of like growing up with two left feet. It’s like they’re forever stuck in that adolescent gawky phase where they just don’t feel like they fit in with the rest of the world.”

Thomas says the disorder has both a genetic and a behavioral component. The family root aspect is so common that Thomas recommends counselors ask the client if there’s a family history of social anxiety. “Sometimes it’s Uncle Charlie who didn’t like going to the family picnics and always kept to himself,” she says.

The treatment Thomas most uses to combat social anxiety is exposure. She encourages her clients to put themselves in social situations and investigate their negative feelings — first acknowledging those feelings and then looking at the reality. In most instances, she says, no one is staring or disapproving.

On a recent Friday night, Thomas took a group of clients struggling with social phobia to a nearby mall. Each person first attached a few pieces of toilet paper to the bottom of his or her shoe, then walked around the mall to see if anyone noticed. Of the six people in the group, only two said someone had spied the toilet paper. “It really helped them see, ’You know, maybe people aren’t always looking at me,’” Thomas says.

Worry without end

Another anxiety disorder counselors say they commonly see is generalized anxiety disorder, characterized by at least six months of persistent and excessive anxiety and worry. Beverly Snodgrass, who works in private practice in Austin, Texas, says people struggling with generalized anxiety disorder have difficulty controlling their “worry thoughts.” They may feel fidgety and have difficulty sleeping. “It becomes so overwhelming that they’re unable to complete the things they need to complete,” Snodgrass says. And it can become a vicious cycle. “If they’re worried about job performance,” she says, “they may become so overwhelmed that they can’t do the things they need to prepare for that or to have satisfactory performance. Therefore, the problem becomes worse. It becomes a self-fulfilling prophecy.”

Snodgrass says some people have a “biological vulnerability” to anxiety. “They may be more sensitive than other people. They may have inherited a nervous temperament,” she says. Experiencing a painful or traumatic event (even a low-grade trauma) can make anxiety even more likely for the person, says Snodgrass, who adds that anxiety serves as a kind of protective shield against experiencing the trauma again.

One effective treatment for generalized anxiety disorder is cognitive behavioral therapy, Snodgrass says. “What we’re focusing on here is bringing awareness to the thoughts that are contributing to anxiety,” she says. Snodgrass asks her clients to challenge the anxious thoughts and replace them with more realistic thinking, such as, “Yes, this is painful, but I’m going to live through it,” she says.

Another technique Snodgrass uses is mindfulness. “The client is taught how to observe thoughts with a healthy distance — being aware that thoughts are events of the mind and they have a beginning and an end,” she explains. Snodgrass helps her clients notice their physical symptoms, such as a quickly beating heart or shaky hands, and acknowledge that they aren’t in any immediate danger. Mindfulness techniques are more helpful with people whose anxiety levels aren’t extremely high, she concedes. When anxiety reaches a certain level, it’s hard for people to effectively manage their thinking, she adds.

Tina Cannon, a Florida psychotherapist and the founder of onlinecounselingblog.com and thebestcounselingblog.com, finds guided imagery useful for helping clients manage their anxiety. Cannon asks clients not only to picture a place they feel relaxed but also to identify what they hear, smell, taste and feel. “I ask them to practice that one or two times a day,” Cannon says. “Then, when they do feel anxious, because they practice it so much, they’re able to use it during those times.”

In the wake of trauma

Post-traumatic stress disorder (PTSD) is another anxiety disorder that has garnered recent attention, mainly because of its prevalence among soldiers returning from the wars in Iraq and Afghanistan. But wartime experiences aren’t the only trigger for PTSD. Any traumatic event in which a person believes his or her life is in danger, such as a rape or a car accident, can open the door for PTSD. More than 7 million adults in the United States have PTSD, and the disorder is more common among women.

One of Snodgrass’ clients, a 25-year-old woman, struggled with PTSD after experiencing traumatic work situations that forced her to leave her job. The situation was so severe that she subsequently spent time in the hospital. After being released, she relocated to Austin to be near her sister.

When the client began seeing Snodgrass, the trauma of her past job, linked with her hospital stay, was causing the woman to avoid the job market. Searching for jobs and going on interviews made her extremely anxious. Together, Snodgrass and the client first worked on relaxation techniques and steps the woman could perform each day to remind herself of her competency. During the treatment, Snodgrass’ client landed a new job. But her anxiety level still ran high. If she made even one mistake at work, it triggered her past trauma, and she feared landing in the hospital again.

After the initial stage of treatment, Snodgrass used a technique known as eye movement desensitization and reprocessing (EMDR), which counselors are finding helpful in treating PTSD. EMDR requires the client to use focused eye movements while bringing to mind a traumatic episode. The idea behind the treatment is that by switching focus between the memory and eye movement, the client reprocesses the memory. In this case, the client kept her eyes on the movement of Snodgrass’ hand while calling to mind the worst memory of her job loss and hospitalization. After three sessions, Snodgrass says the client’s memories had become less disturbing to her.

“It takes away those intense feelings about whatever that trauma was,” says Cannon, who also uses EMDR in treatment. “They still remember it, but they don’t have that immediate connection of ’It’s all happening all over again.’ It doesn’t change the way they remember it; it changes how they feel about it. It changes the emotions associated with it.”

Plagued by panic

Panic disorder is another common anxiety disorder that some counselors treat. Panic disorder is sometimes coupled with agoraphobia, which literally means “fear of the marketplace.” When agoraphobia is present, people become afraid of being in a place or a situation in which it would be hard for them to escape or to get help if they had a panic attack. Cannon notes that panic attacks can happen in places as varied as a certain store that gets overcrowded or while driving in a car on the highway. “Clients usually describe (the panic attack) as an intense fear where they felt like they were going to die or lose control,” she says. “Then they get this urgent desire to flee the situation.”

Medication can often help a person struggling with panic attacks, Cannon says. Regarding therapy, she recommends first helping clients to identify the trigger for the panic attack, such as recalling a traumatic event or phobia. Then the counselor can assist clients in changing the thinking patterns that are keeping them from overcoming their fears and changing their reactions to anxiety-provoking situations. Cannon recommends counselors try desensitization techniques such as EMDR or exposure and response prevention. She adds that deep breathing exercises will aid in relaxation and anxiety management.

Thomas also sees a large number of clients with panic disorder. When she began working at the Anxiety and Stress Disorders Institute of Maryland, she says the institute’s professionals concentrated mainly on cognitive behavioral therapy. Now she uses “third-generation” cognitive behavioral therapy, focusing more on acceptance. Many counselors still teach distraction and relaxation techniques to clients. Although those techniques are good in the short term, Thomas says, they can lose their potency after a time. Thomas teaches her clients that they can be OK with their feelings of anxiety, which essentially separates the feelings from the perceived danger, she says.

Thomas compares the physiological feelings involved in a panic attack to riding a roller coaster. “Most people get off the roller coaster and say, ’Oh, cool, that was fun. Let’s do it again,’” Thomas says, but people more prone to anxiety might say, “Oh, I didn’t like that, and I don’t want to do it again.”

“A lot of it is difference in attitude toward the symptoms,” she says.

Last year, Thomas flew with a group of five people on a day trip to the Rock and Roll Hall of Fame and Museum. They flew out of Baltimore in the morning and flew back from Cleveland later that evening. For most people, the trip wouldn’t have been a big deal. But for this group, it was an amazing feat because all, save for Thomas, were afraid of flying.

Thomas specializes in helping clients come face-to-face with the things they fear. During the past few years, she has developed a comprehensive program for clients who are afraid to fly. About two weeks before her group flew to Cleveland, she took them to the airport to talk to a pilot about flight safety. “They usually find it very reassuring,” Thomas says. The point of visiting the airport and then waiting two weeks before flying, she explains, is so clients will learn to cope with the anticipatory feelings.

Whether the situation involves experiencing panic attacks in an elevator, on the highway or on a plane, Thomas says helping clients practice those situations can assist them in overcoming their fear. In recognizing the sensations and feelings that accompany anxiety and panic, clients realize they can be in those situations and emerge unharmed. “They begin to habituate to the sensations and feelings,” Thomas says, adding that clients can then recognize the initial jolt of adrenaline. “This is a very normal reaction, but it doesn’t necessarily mean you’re in danger.”

Tips from the pros

These experts agree that no matter what type of anxiety disorder a client seems to be presenting with, a counselor’s No. 1 priority should be ensuring the client has had a full medical checkup. Medical conditions such as thyroid problems can sometimes mask as anxiety, Thomas says.

Expressing faith that the situation can improve is another helpful tactic, Snodgrass says, but be realistic with the client. Reassure clients that while things might not change overnight, they will get better. At the same time, she says, help clients understand that it’s not realistic to expect that all their anxiety will disappear or that they’ll never feel anxious about anything again.

Don’t be afraid of the anxiety, Thomas advises her fellow counselors. “Anxiety is not dangerous, and if you can sit there (with the client) and hold their anxiety and not be afraid, then that gives them courage that they can change.”

Snodgrass recommends counselors help clients see how they might be unintentionally reinforcing their anxiety and then assist them in eliminating those patterns. She offers the example of a person who has great anxiety about grocery shopping. The counselor should arm the client with techniques, such as breathing exercises, to use when he enters the store and begins feeling anxious. Leaving the store will only reinforce the sense of anxiety, she says. “It further enhances the idea that I can’t handle it — ’The last time I went to the store, I left.’ It makes them more anxious the next time.”

Counselors must also be careful not to reinforce their clients’ anxiety, says Snodgrass, recalling that she learned that lesson firsthand. One of her clients, a man in his mid-30s, was struggling with anxiety caused by feelings of social isolation and incompetence. Snodgrass allows her clients to set up a “coaching call” when they’re attempting to do something they’ve been working on in treatment. Although that approach is beneficial with many of her clients, it had a negative effect on this particular man. “He was calling me, but it was reinforcing his idea that he couldn’t handle (his anxiety),” Snodgrass says. She adapted the plan so the client would call her after he had utilized the relaxation techniques instead of before, and that change had a positive impact. Reinforcement and anxiety can be “tricky” topics, Snodgrass admits. Happily, she says the client is now reconnecting to his feelings of competency.

Although anxiety at the disorder level is neither healthy nor enjoyable, ACA member Neil Soggie, an assistant professor of psychology at Atlantic Baptist University in Canada, says some anxiety is necessary. He agrees with Snodgrass that total elimination of anxiety is neither realistic nor advisable. Soggie, who wrote the Professional Handbook for Mood and Anxiety Disorders, knew someone who struggled with anxiety and took medication to combat it. When on her medication, however, an antisocial tendency came to the fore that had been held in check by her anxiety of getting caught. “So while she felt fine, she left a wake of destruction a mile wide while on her antidepressants,” Soggie says. “This is a reminder that there is a positive role of anxiety and that we all need a little anxiety in our life in order to help it be meaningful and keep us sane and civil.”

Lynne Shallcross is a staff writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org.

Editor’s note: This is the second article in a two-part series examining how counselors can work more effectively with clients who hold strong religious beliefs. The first article, which appeared in the July issue, addressed the historical tension between religion and the mental health professions, reasons counselors avoid bringing up issues of faith with clients and the importance of counselors developing religious multicultural competency.

A growing number of studies suggest a positive connection between active religious faith and various measures of psychological well-being, including career satisfaction, the ability to cope, a sense of meaning and purpose in life and overall levels of happiness. “From my biased point of view, I think religious clients have fewer mental health problems,” says Robert Brammer, an American Counseling Association member who considered going into the ministry before becoming a counselor. “There’s this sense of peace for them in giving up control to a higher being. But there’s also more conflict for these clients when things aren’t meshing with their worldview. Reconciling their point of view with their religious belief is sometimes very hard.”

Helping clients who are guided by their faith can be a challenge, Brammer says, especially when the counselor doesn’t espouse the same beliefs. In such cases, the counselor must focus on respecting the client’s beliefs and the client’s ability to choose what is best for them, says Brammer, director of both the mental health and school counseling graduate programs at Central Washington University.

Brammer recalls when he was a private practitioner and was counseling a woman who remained in an abusive relationship because of her religious belief that she was to submit to her husband and that divorce was wrong. “As a counselor, I couldn’t encourage her to be submissive as she believed she was supposed to be,” Brammer says, “but I told her I understood that it would be hard for her to go against her religious beliefs and that she would ultimately have to make a choice. Sometimes, when the religious person’s views are in conflict, they simply have to decide which one to stay with for the moment.”

The woman chose to leave counseling and make the best of her marriage according to her interpretation of the tenets of her faith. However, six months later, Brammer says, she came back. “And this time, she was ready to move on. Perhaps that’s one of the key components to counseling religious clients — give people time to work things out when there are contradictions between their two worldviews.”

Communicating respect and acceptance

Before becoming professor and chair of the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, J. Scott Young had a private practice in Mississippi, where religious views tended to be conservative. “There’s a lot of fear in the counseling profession around that real conservative thinking,” Young says. “But I just look at what this person is saying and ask if it’s working for them. As counselors, we need to be intellectually curious with these clients and open to looking at the strengths their religious beliefs provide. Don’t prejudge their beliefs harshly, and don’t be rigid. If you have a hidden agenda in wanting to change something in somebody, it will never work. It will only sabotage the relationship.”

When Lisa Jackson-Cherry, immediate past president of the Association for Spiritual, Ethical and Religious Values in Counseling, was working as director of the mobile crisis team for Baltimore Crisis Response, her team encountered a client who stated her belief in and need for a root doctor. As described by Jackson-Cherry, root work is a combination of West African religion, herbal folklore and Christian beliefs (most often Catholic practices). It includes the ancient belief that everything in creation is filled with spiritual significance. Taken aback by the client, team members initially dismissed her beliefs as silly. “But I said, ’No, let’s just find this person what she thinks she needs. Let’s find her a root doctor,’” Jackson-Cherry says. “If you don’t necessarily believe what your client believes, it’s important to get information about why that belief is important to them. Then, as counselors, we need to figure out why we have a problem acknowledging the benefits to the client.”

Being open to a client’s religious beliefs as a counselor is one thing; making the client aware that the counselor’s office is a welcoming place to discuss matters of faith and religious identity is another task altogether. Most clients aren’t going to assume this on their own, says Jackson-Cherry, who adds that counselors must “give clients permission to share their story” by asking nonthreatening questions about their religious background (or lack thereof) during the intake.

Jill D. Duba concurs and says counselors who fail to ask those questions often end up with an incomplete picture of their clients. “Do you realize the depth, the meaning it holds when this person says that they’re Baptist, for instance? As counselors, we have to sit with that and ask what that means to this person,” says Duba, an associate professor in the Department of Counseling and Student Affairs at Western Kentucky University. “That’s a perfect door, a perfect opportunity, to start a conversation.”

Richard Watts prefers to broach the subject on the intake form because he thinks certain clients are more likely to overstate the importance of religion in their life if the counselor verbalizes the question. “I include a statement asking if their religious and spiritual values are important to them and asking if they would like them included in the counseling process. This tips me off to whether we should explore this topic further and tells the client that their religious values, regardless of what they believe, are welcome here,” says Watts, editor of the ASERVIC journal Counseling and Values and director of the Center for Research and Doctoral Studies in Counselor Education at Sam Houston State University.

In subsequent sessions, suggest Brammer and Jackson-Cherry, counselors can reopen the door to discussions of faith by asking clients whether they attended a religious service that week. Jackson-Cherry says a handful of clients have also asked her if they could open up the counseling session in prayer to help them relax.

Occasionally, counselor self-disclosure may be appropriate for increasing a religious client’s comfort level. “But it should be done judiciously,” Watts advises. “Ask yourself, “Am I doing this for the good of the client, or is this about my own stuff?’”

Self-disclosure doesn’t mean counselors need to reveal their every view on religion, says Young, coauthor with Craig Cashwell of Integrating Spirituality and Religion Into Counseling, published by ACA. But when seeing religious clients in Mississippi who were often wary of how a counselor might view them, Young says it sometimes helped to reveal that he had grown up in church. “Talk to these clients about their concerns and anxieties and explain that you’re not trying to influence them away from their beliefs,” he says. “Essentially, what they’re trying to figure out is do you understand where I’m coming from? Are you going to judge me? If I talk about God and Scripture, are you open-minded as a counselor? What they really want to know, I think, is are you OK with me? They don’t generally need to pick apart a counselor’s every theological nuance.”

Watts, who has his master’s degree in religious education from Southwestern Baptist Theological Seminary and originally planned to return to church work after earning his doctorate in counseling, is no stranger to counseling clients of other faiths, including pastors and rabbis. An avid reader of theology and world religions, he likes to “take a ’not knowing’ position with religious clients and let them be the experts about their spiritual beliefs. For instance, I talked recently with a Hindu client and asked, ’How does that faith guide your life?’ By doing that, I’m not imposing my biases, and it’s very empowering for clients when I invite them to tell me what they believe. When they see that I’m interested in their beliefs, it makes it safe for them. Otherwise, they may fear the counselor is going to think their belief is pathological.”

Watts also challenges counselors to get comfortable using the basic religious language and belief system of the client. In working with a Hindu client, for example, Watts might help the client investigate life choices as filtered through the law of karma, which makes individuals responsible for their own destiny. “I would use a reflective dialogue to explore whether the actions this person is taking are positive or negative,” Watts says. “Or we might talk about the Hindu notion of dharma, which addresses one’s responsibilities in life and how people make meaning of their life.”

Reaching out

Collaborating with religious leaders is another way to make clients of faith more comfortable with counseling, Brammer says. “Collaboration also makes it more holistic for the client,” he says, adding that it’s important for the counselor and the religious leader to clearly define ahead of time the role that each will play.

One of Young’s counseling colleagues who was in private practice in Mississippi took the initiative to visit several churches in the area. “He said, ’We can be your mental health place when facing something beyond your scope as a minister,’” Young says. “Ministers are almost inevitably looking for good referral sources because a lot of the issues they’re confronted with are not in their training.”

Clients who hold strong religious beliefs are much more open to counseling when referred by a pastor or other religious leader, Young says. However, accepting referrals does not mean the counseling should be conformed to be in lockstep with certain religious teachings, he adds. If a situation arose in which a religious leader tried to dictate the direction counseling should take, Young says, “I would say, ’It sounds like you want me to use your theology with this client, but I’m not a theologian; I’m a licensed professional mental health counselor.’”

Another way counselors can initiate relationships and start building trust with religious groups is to simply be present in a supportive way when these groups host events, says ACA member LaVerne Hanes Stevens, an ordained Protestant minister who is also employed by Chestnut Health Systems, where she trains clinicians to do substance abuse assessments. Her church regularly holds forums on women’s issues. “It’s nice when a local provider comes just to be a participant, to show their personal and professional interest,” she says. “That stands out to us.”

Stevens thinks it’s incumbent on counselors — especially those working in the public sector — to initiate outreach with faith-based organizations in the community. When she was working in the Substance Abuse Services division of the Behavioral Health Authority in Richmond, Va., she and other from that division were involved in regular meetings with inner-city clergy members of all faiths.

“We didn’t want the local clergy to be suspicious of the system. We wanted to build trust,” Stevens says. “We reached out to them and said, ’Let’s talk about substance abuse and mental health problems in the community, because people in the community often come to their clergy first. Let’s talk about some of the common treatment barriers faced by those we serve. Let’s talk about what we can do on our end and what you can do on your end.’ It really boiled down to ’Hey, this substance use epidemic is costing all of us something, so let’s work together.’”

“We found those meetings to be very helpful because we were able to explain the referral and intake process to the clergy,” she continues. “It helped them to put a face with the system and to hear that we had some of the same goals, including safety and wholeness for the people in our communities.”

As a result of those meetings, Stevens was enlisted to serve as the consultant to the leaders of a local church’s substance abuse program. The church also invited Stevens to be the keynote speaker at its annual Recovery Month celebration. “It was a truly unique partnership that helped the community see the church and the local provider system working together collaboratively,” she says.

Finding strength in the sacred

Longtime ACA member Kenneth Anich says counselors can work more effectively with religious clients by focusing on a key question. “How can you utilize the client’s religious beliefs — whatever they are — to help them through their depression or other presenting problem? Counselors should use the strengths that are already there,” advises Anich, an associate professor of psychology at Divine Word College and a member of the Society of the Divine Word, an international congregation of Catholic missionary priests.

Many times, this means helping clients to reframe their struggles or their approach to those struggles by reviewing the guidance and examples provided to them in their faith traditions. Watts recalls working with a devout Catholic client who was worn down by guilt over some of the choices she had made. Employing his “not knowing” perspective and using an “imaginary reflecting team member” technique, Watts helped the woman tease out an alternative perspective from within her faith tradition. “I said, ’Remind me, was (the Apostle) Peter the first pope of the Catholic Church? What would Peter say about some of the mistakes he made, including denying Jesus Christ three times? You know, Peter made some very big mistakes, but he became the first pope. So what do you think he would say about your mistakes?’ She hadn’t been able to generate any forgiveness for herself from her own perspective, but she could using the perspective of Peter.”

Counselors can often help clients of faith work through problems by reviewing the dissonance between their beliefs and their actions, Duba says. Many of these clients also struggle with what she terms the “should” syndrome: I should stay married even though he’s beating me; I should be more successful because that’s what God wants; I shouldn’t be this upset because I know God thinks …

“But counselors have to be very careful challenging the thinking of these clients,” Duba says, “because you’re not just challenging them. From their viewpoint, you’re challenging the higher power they believe in. Sometimes, you have to be willing to stay stuck in that problem with them for a while. It’s not just helping them through the problem but helping them think about the higher power they believe in. It’s almost a spiritual journey.”

Like Watts, Duba often finds it useful to help clients of faith attain a “higher” perspective on their struggles. “One of the things I’ve tried is asking them to close their eyes and imagine that God is in the room,” she says. “I ask the client, “What would He say to you? What would He be doing?’ It’s almost like an empty-chair technique but with God sitting there.”

Sometimes, Young says, clients need to be reminded of the strength available to them in their professed religious beliefs. He recalls working with a Christian client whose battle with depression was distorting his view of life. Based on the client’s stated beliefs, Young encouraged him to tap into the promise of hope, love and meaning so prevalent in his faith tradition. “We explored some of those things, and then I challenged him to interrupt the negative thoughts he was having — basically, cognitive behavioral thinking. He was eventually able to stop and say, ’Oh, that’s my depression saying that stuff to me.’ He could then filter those negative thoughts back through his religious belief and once again see beauty in the world.”

Balancing principles

Religious belief can be either a facilitator or a detriment to mental health, depending on how clients choose to apply it, Watts says. “Religious faith helps people connect to God, reach out to others and contribute to humankind, which is the focus of most world religions,” he says. “That provides a sense of meaning and purpose, and there is a good bit of research showing that people who have meaning and purpose in their lives tend to be more mentally healthy. However, if a person’s beliefs are focused externally — on rules, regulations and judging others — the effect is more likely to be negative. When the focus of the religious belief is on judging rather than loving, it’s not as mentally healthy.”

Watts has found that some people come to counseling because they were raised in a fundamentalist religious background and left it behind when they grew up. “Now, however, as adults, they feel a lack of meaning in their lives and are struggling to rediscover that meaning again,” he says. “Because of their punitive and rigid upbringing, they have this view of God that is twisted, and they have a hard time separating the meaning of spiritual interaction with God from rote, religious rigidity. As a counselor, I may ask them if that is something they would now like to explore, and we’ll talk about the difference between religion and being in relationship with God.”

Other clients may focus their attention on a single aspect of their belief or religious teachings and use it as a prop to maintain their dysfunction, Anich says. Many times, he adds, these clients are misinterpreting that teaching or belief. “If clients are using an aspect of their religion in a dysfunctional, rigid way, it’s often helpful to encourage them to seek the advice of their rabbi, mullah or pastor to get a more informed perspective,” he says.

“I heard someone say that fundamentalism of any type, including liberal fundamentalism, is the major problem in the world,” Young says. “Rigid, intolerant thinking paints people into corners. … Frequently, people will attach to one idea in Scripture, or another sacred text, and ignore others. From a clinical point of view, I will often say (to Christian clients), ’What about these other ideas found in the Bible about free will, grace, forgiveness? What about the fact that the price has already been paid by Jesus?’”

“I do this in an explorative rather than a confrontational style,” Young adds. “I grew up in that world (of conservative religious thought), and I can understand where these people are coming from. But I can also challenge them to look at the places where they are getting stuck.”

With Christian clients, Watts likes to use biblical passages. “I can often show them how they have embraced one aspect of their faith while ignoring others and help them look for balancing principles in their lives,” he says. “Plus, the Bible is full of guidance for being in relationship and getting along with others.”

In one instance, Watts was counseling a conservative Christian couple. The husband was using a small portion of Scripture (“Wives, submit to your husbands …”) to keep his wife in line. “The wife wanted him to be the leader of their household,” Watts says, “but without being a doormat herself.

Watts invited the man to look at the next part of the passage addressed to husbands (“Husbands, love your wives, just as Christ also loved the church and gave Himself for her”). They talked about how the passage directed husbands to a deep, sacrificial love. Then Watts asked the husband, “Why are you reading her mail?” — meaning why was he focusing on what the Bible called his wife to do rather than focusing on the Scripture’s explicit instructions for him?
Watts then asked the couple where they thought love was best described in the Bible. They chose 1 Corinthians, Chapter 13, which includes verses such as, “Love is patient, love is kind. It does not envy, it does not boast, it is not proud.”

“I then substituted husband for love in each one of the descriptions throughout the chapter,” Watts says, “and asked the wife how she would feel about respecting her husband if he were genuinely trying to love her like that.”
The husband was visibly upset, and the wife called Watts before the next session to say they wouldn’t be coming back to counseling. But when the husband spoke with his pastor, the pastor agreed with Watts. The couple switched churches, and that pastor told the husband the same thing. After hearing similar messages delivered by other preachers on both television and radio, the couple again enlisted Watts for counseling. “The husband said to me, ’I finally figured God was trying to say something to me,’” Watts recalls.

Returning to counseling, the husband revealed that based on how he had been raised, the only way he had learned to engage in relationships was with a take-charge personality. But with the guidance pointed out to him from his own faith tradition, he was now more willing to work on his own baggage rather than making his wife the scapegoat for their problems.

Putting problems into a religious context

Numerous values and concepts shared by world religions can be woven into the counseling process to help clients of faith, Duba says. Among the most prominent, she says, are hope, forgiveness (which helps clients to move through tough situations) and faith that there is something better (which helps clients to reframe what is happening to them).

“No. 1, to me, is the importance around forgiveness, both of yourself and others,” adds Anich. “At the core of almost every client dysfunction is a failure to forgive, which means that they have to continue carrying around baggage. As a treatment, counselors can help clients work through that process and ritualize forgiveness. I think ritual has a very powerful place in session.”

Anich cites the story of a therapist who was working with a woman experiencing intense guilt and an inability to forgive herself after having an abortion. The therapist gave the client a baby doll and asked her to care for it. After a period of time, they buried the doll together. “Just going through that ritual was healing for the woman because it symbolized a letting go,” Anich says.

Various faith traditions speak to the need for believers to change their perspective, and sacred texts of many faiths provide examples of individuals whose lives were transformed after their perspectives changed, Watts says. “So I might pull out that concept in a counseling session and talk to a Christian client about the Christian faith’s focus on repentance, which is essentially having a change of mind that leads to a change in behavior. Basically, we’re talking about something similar to cognitive restructuring, but by using this concept, it resonates with their religious perspective.”

Brammer likes to operate from a narrative point of view and has found that bringing metaphors into the session often makes it easier for the counselor and client to reach a shared worldview. He recalls one client who believed her 3-year-old son was demon-possessed because he had attacked his younger sibling. She had gone so far as to have her church perform an exorcism. “Based on her belief, I couldn’t just say to her, ’This is simply sibling rivalry,’” Brammer says. “We had to find some shared way of viewing the problem. So we would talk about ’light’ and ’darkness.’ How do we work through the darkness in her son and get back to the light? How do we cultivate the light in him?”

Stevens believes counselors can best assist religious clients by helping them think through their theology of suffering and struggle. “Do they understand struggle as a growth opportunity or a character flaw? Do they perceive God as One who causes, allows or protects them from suffering? What does the client believe about human nature? Is it good, evil, redeemable? With Christian clients, it can help to remind them that the Bible says there will always be a conflict between one’s old, fallen nature and the new, redeemed nature. However, the Bible also says there is no condemnation to those who are in Christ Jesus. This often helps to normalize their struggle while also giving them permission to move beyond the old, shame-filled, condemning self-talk.”

“Counselors can help clients learn to lean into their pain, reminding them that struggles provide us with opportunities for personal growth, to connect with God and to make contributions to the community,” she continues. “I stress to clients that even the most challenging times can be the soil for good things to come, congruent with their faith.”

To work effectively with religious clients, Stevens advises counselors master some straightforward steps. “Do more inquiring than suggesting with these clients. Know how to guide them to their spiritual support systems. Respect that counseling and faith should be working toward some of the same goals. Finally, let the client’s faith ultimately guide them to wholeness, because wholeness as defined by secular counseling may be too self-serving for some religious clients to embrace.”

Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@counseling.org.