Counseling Today, Knowledge Share

To whom shall I refer?

Cowritten by Jill L. Snodgrass, Devlyn McCreight and Michael R. McFee December 3, 2014

After three sessions with “Alicia,” a 45-year-old African American woman who was the victim of acquaintance rape, the treatment goals centered on addressing her symptoms of post-traumatic stress disorder (PTSD). The perpetrator of the rape had been a member of Alicia’s church. Although Alicia had subsequently stopped attending worship, the counselor viewed this strictly as a symptom Authors_Decof Alicia’s PTSD. The counselor didn’t consider that Alicia might also be experiencing serious struggles with her faith until Alicia fervently stated, “I will never forgive God. I was a woman of deep faith, always doing the ‘right’ thing. I led Bible study, served on the church council. But I hate God. I really, really do. God let me be raped. God was there.”

Attending to clients’ spiritual and religious concerns as they relate to mental health is a cultural competency. What if the spiritual and religious issues presented surpass the counselor’s competence or level of comfort, however? To whom shall you refer? According to the Competencies for Addressing Spiritual and Religious Issues in Counseling, espoused by the Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC) and supported by the American Counseling Association, an ethical counselor “can identify the limits of his or her understanding of the client’s spiritual and/or religious perspective and is acquainted with religious and spiritual resources, including leaders, who can be avenues for consultation and to whom the counselor can refer.” 

 

It can be difficult for a counselor to make an appropriate referral, however, if he or she does not possess a basic understanding of the types of spiritually integrated services available. This article presents overviews of Christian counseling, pastoral counseling and spiritual direction to help counselors make informed decisions regarding referral.

Christian counseling

Professional Christian counseling is performed by a diverse community of individuals, including licensed professional counselors, psychologists, social workers, clinical nurse specialists, marriage and family therapists, and psychiatrists. In most instances, the practice of Christian counseling reflects dual training. Individuals who practice Christian counseling obtain their graduate degree from an accredited graduate school and then go on to receive additional theological training. There are religiously affiliated graduate programs and seminaries in every state that offer training in counseling. 

The primary difference between secular and Christian counseling from the client’s experience may best be described as an issue of trust and ease in developing the therapeutic alliance. The first question many religiously oriented clients ask is “Can my therapist accept or understand my Christian spirituality?” This potential hurdle heightens their anxiety about starting counseling and prevents many Christians from seeking treatment altogether. For many of these clients, discovering a counselor who understands and shares their worldview makes developing the therapeutic alliance more fluid and facilitates therapeutic work.

The epistemological foundation (how knowledge is known) of Christian counseling includes spiritual and theological knowledge dating back to St. Augustine and even beyond to ancient Hebrew and Judaic views of knowledge. There is a rejection of the predominant secular worldview. For many Christians, secularism is understandable in the marketplace but becomes offensive and fails to explain concerns of family and spiritual life. Theoretically speaking, Christian counseling replaces a secular anthropology with a spiritual religious anthropology and, specifically, a biblical anthropology. At the same time, Christian counseling holds a deep respect for the contributions of social and natural sciences, while also recognizing the limits of the sciences in addressing psychological and especially spiritual struggles. In fact, there is a long historical tradition of Christian writers and thinkers addressing issues that today we view as psychological. The historical practice of counseling within the Western Christian church was most often referred to as “soul care.”

The rich history of soul care offers more than a thousand years of practices that predate the modern psychology movement inaugurated by Sigmund Freud. Stephen Greggo and Timothy Sisemore provide an excellent history of soul care in their edited book Counseling and Christianity: Five Approaches, published in 2012. They describe how The Confessions of St. Augustine (still a great read for many clients) and Summa Theologica by Thomas Aquinas reflect deep Christian thought while interacting with the secular thinking of Plato and Aristotle. In the 1600s, Richard Baxter and several other Puritan writers eloquently described the nature of melancholy and depression. Reading certain passages from sermons by Baxter or Thomas Brooks is similar to reading the clear descriptions of the vegetative signs of melancholic depression in the Diagnostic and Statistical Manual of Mental Disorders

For modern counselors, one of the most interesting aspects of this lost literature is that Christian writers clarified aspects of obsessive-compulsive disorder (OCD) in the 1600s. In 1660, Jeremy Taylor, an English bishop, used the word scruples in The Rule of Conscience and clearly illustrated the nature and course of obsessive-compulsive phenomena. Taylor’s writings helped illustrate the diagnosis as well as the treatment for what is now called OCD. Scrupulosity is an often-misunderstood form of OCD involving religious and moral obsessions developed in the effort to pursue faithfulness and integrity in one’s spiritual beliefs. A good overview of scrupulosity by the International OCD Foundation can be found at iocdf.org/brochures-and-fact-sheets/

Scrupulosity is said to be a hazard of any type of spirituality or religion and is viewed as an “equal opportunity offender” across all religious systems. The ideal treatment is a modified exposure and response prevention model that includes consultation with a spiritual leader. Christian counselors trained in the treatment of anxiety disorders may utilize these methods and augment treatment with historical pastoral practices that make the interventions both more accessible and tolerable to the client.

Well-trained Christian counselors not only work from a perspective of using evidence-based practices but also draw on lasting historical pastoral practices such as the use of prayer from the client’s faith tradition. This may take the form of homework or happen as an experiential exercise in the counseling session. Exploration and discussion of the client’s understanding of biblical texts may be part of a key intervention for some individuals. A Christian counselor may redirect a client to practices of thankfulness and away from judgmental and moralistic thinking. This redirection serves as a reminder that God’s greatest commandment was to love. The use of metaphors and allegories from Scripture can help clients find meaning and develop motivation and strength to face life circumstances.  

Recent and continued polling by the Gallup Foundation, the Pew Research Center and the Center for the Study of Religion at Princeton University indicates that the majority of Americans believe in God in some way. The number of religiously oriented clients is far greater than the number of secularly oriented therapists. For this reason, it is a good career move for counselors to increase their cultural competency by including some training in Christian counseling or to network and develop a referral source with a local Christian counselor. Some strategies include attending a continuing education training event offered at a regional Christian graduate school, attending a continuing education workshop provided by one of the various Christian professional organizations (for example, see actheals.org, aacc.net and caps.net) and participating in an ASERVIC division event at the next ACA Conference. You can also use a listing database (such as findchristiancounselor.com or aacc.net/resources/find-a-counselor) to obtain contact information and reach out to local Christian counselors. 

Finally, local networking with pastors and colleagues of religious convictions may be most profitable. Most local clergy develop and keep their own referral lists and are careful in the referral process. This means that if you do not have a direct relationship with them, they will not refer to you. The best way to develop these relationships is to involve the clergy of your practicing clients in the same way you might involve a primary care physician. Obtain a release from your client and reach out to local clergy. Work in a phone call and set up a face-to-face meeting. When you are effective with one of your clients, you will have the gratitude of your local clergy — and likely another resource.

Pastoral counseling

Like Christian counseling, pastoral counseling is also performed by a community of diverse individuals with graduate training in marriage and family therapy, counseling, social work, psychology and clinical pastoral counseling. These individuals most often embrace a bicultural identity, moving fluidly between the cultures of secular mental health practice and religious community. They are less prey-Smalllikely than Christian counselors to reject a secular anthropology and worldview and more likely to explore how God or the transcendent manifests in both secular and religious milieus.

Pastoral counselors are bound by the same state licensing laws that apply to any licensed mental health professional. At present, only six states license the title pastoral counselor. Therefore, depending on their training, pastoral counselors are more often licensed as clinical professional counselors, marriage and family therapists, professional counselors and psychologists. Many pastoral counselors also receive endorsement from their religious communities (for example, receiving the designation of “ordained pastoral counselor” from the American Baptist Church), but this is considered a validation of an individual’s calling to do clinical work, not a license to do so. Religious endorsement is a requirement for certification in the American Association of Pastoral Counselors (AAPC). This certifying organization convened for the first time in 1964 with the aim of holding pastoral counselors accountable to the ethical practice of religiously integrated mental health care. At the time, most pastoral counselors were clergy with psychological training but not licensed mental health professionals.

The foundation of pastoral counseling is synonymous with that of Christian counseling, with both being grounded in the same tradition of Judeo-Christian soul care outlined earlier. According to Charles Gerkin, the historical tradition of soul care was threefold: worship organized by priests, the continuity of tradition guided by prophets and practical guidance in everyday life provided by wise leaders. This threefold tradition was evidenced in the ministry of Jesus and served as the foundation for the helping acts of healing, sustaining, guiding and reconciling that remain central to pastoral care and counseling today.   

The history of pastoral counseling diverged from that of Christian counseling in the early 1960s around the time AAPC was formed. Bruce Narramore wrote an inaugural essay for the Journal of Psychology & Theology in which he advocated for the distinctiveness of Christian counseling as grounded in the authority of Scripture, rigorous academic study and commitment to Christ. Narramore viewed pastoral counselors as being overly influenced by the liberal church and not advancing a biblically sound perspective. Moreover, Christian counseling was populated largely by psychologists and psychiatrists, whereas pastoral counseling was dominated by clergy and religious leaders with psychological and mental health training. The distinction between the two disciplines became clearer in the 1990s when pastoral counselors largely embraced a postmodern, communal contextual model of counseling that privileged the integration of theology and spirituality and generally moved further from dependence on the authority of Scripture.

According to Carrie Doehring, associate professor of pastoral care and counseling at Iliff School of Theology in Denver, pastoral counselors are distinct from those who practice spiritually integrated counseling and psychotherapy because pastoral counselors are theologically educated and thus theologically accountable to the religious organizations that endorse them. Those trained as pastoral counselors in today’s postmodern milieu are taught to counsel clients from any and all religious traditions and to recognize covert religious experiences characterized by Christian theological, phenomenological or universal approaches.

Clients who present with problems they conceptualize through a religious or spiritual framework, or who hold their particular religious, spiritual and theological beliefs as primary and at the foreground of life, may benefit from counseling with a pastoral counselor. In addition, clients who have experienced spiritual or religious abuse, including victims of sexual misconduct by clergy or laypeople within a religious community, may find pastoral counseling especially helpful. Finally, referrals include all clients — from all religious traditions and practices, as well as atheists and agnostics — who wish to explicitly engage religious coping in their treatment. 

Several resources are available if you are interested in making a referral to a pastoral counselor in your area. AAPC provides the names of pastoral counselors throughout the United States who have received advanced-standing credentialing within the organization (see aapc.org/quick-links/find-a-counselor/). Many colleges and universities offer graduate programs in pastoral counseling, and the associated faculty and administrators would likely assist local clinicians in locating appropriate referral resources. For a list of pastoral counseling programs in your area, visit gradschools.com/search-programs/pastoral-counseling. As previously noted in reference to Christian counseling, local religious leaders often refer congregants for mental health services and can therefore be excellent resources in identifying local pastoral counselors.

Spiritual direction

Pastoral counseling, Christian counseling and spiritual direction are all practices in soul care. However, whereas the first two are clinically focused approaches aimed primarily at reducing psychopathology and solving problems in the life of the client, the goal of spiritual direction is the enhancement of one’s spiritual life through attunement to God’s presence and action. Spiritual direction, sometimes referred to as spiritual guidance, spiritual friendship or holy listening, is grounded in an ancient ascetical practice. It is a process of discernment in which two or more individuals gather to understand God’s will. The focus is on the directee’s relationship with God and the cultivation of his or her spiritual gifts.

In its broadest definition, spiritual direction is not limited to Christianity. Adherents of various faiths participate in these sacred relationships: gurus and disciples, shamans and initiates, roshis and students, among others. Manifestations of spiritual direction are found in a variety of historical and contemporary traditions — just think of Socrates, the Sufis of Islam and the bodhisattvas of Buddhism. Although this article is limited to discussing spiritual direction in the Christian context, it should be noted that clients of various faith traditions may benefit from engaging in spiritual guidance.

Within a Christian framework, spiritual direction is founded on the belief that the Holy Spirit dwells within us. New Testament Scriptures, including passages found in Romans, 1 Corinthians and
2 Timothy, recount the promise Jesus made of the indwelling of the Holy Spirit. “Do you not know that you are a temple of God and that the Spirit of God dwells in you?” (1 Corinthians 3:16). 

Just as Jesus guided the disciples, by the early fourth century Egyptian monastics had created elder-neophyte relationships in which the elders, who had already struggled to align their hearts with God’s will and ways by grappling with the hardships of desert living, offered nurturance, support and correction to others. Over time, an oral tradition emerged that produced the wisdom and sayings of the desert fathers and (although largely omitted from the history) desert mothers as well.

In the sixth century, Benedict and his Rule furthered the practice of spiritual direction by enhancing communal life and the formation of new members. The head of the monastery was viewed as a “spiritual father” who guided the novices, together with the practices expounded in the Rule, to greater intimacy with God. Spiritual direction was an evolving form of soul care. According to Martin Thornton, in the Scholastic period (beginning in the 11th century), spirituality was more “formally studied and analyzed — direction became more of a science than an art.”

The tumult of the Reformation informed three voices that transformed the practice of spiritual direction: John of the Cross, Teresa of Avila and St. Ignatius of Loyola. Their writings combine astute psychological wisdom with a nonpaternalistic approach to direction. The director was considered a witness of God, not in a position to judge directees’ decisions or behaviors, but with the goal of mediating divine action. The post-Reformation period produced many sage spiritual directors, among them laywomen and laymen who wrote prolifically on how to practice the pastoral skill of direction.

Spiritual direction experienced a renaissance in 1970s’ and 1980s’ America due in large part to the influences of the Second Vatican Council and the women’s movement. In the spring of 1973, a small group of spiritual seekers from a variety of denominations came together at the request of Episcopal priest Tilden Edwards for a retreat. That group evolved into a community of “pilgrims,” calling itself Shalem, the Hebrew word for wholeness. The group formed a spirituality center at Washington National Cathedral and began offering classes in contemplative prayer and spiritual direction. The Mercy Center in Burlingame, California, emerged in the late 1980s from a similar collective interest and commitment. And by 1991, Spiritual Directors International had been born as a nonprofit organization for networking and support of spiritual directors in the United States and abroad.

Today, spiritual directors and spiritual direction centers are prevalent throughout the nation and the world. Although the Holy Spirit is the true “director,” numerous men and women, lay and ordained, are trained in the art of spiritual direction. More than 300 training centers are located throughout the country, and many more directors are educated through informal apprentice-style preparation. While many priests, pastors and vowed religious individuals offer spiritual direction, it is a charism or gift, not a skill endowed simply by ordination. Unlike counseling, spiritual direction is not governed by an accrediting body; therefore, although many training programs offer certification, there are no formal qualifications or education requisite for practice. 

In Seeking Spiritual Direction, Fr. Thomas Dubay advises seeking a director with the following qualities:

1) A person of true prayer — liturgical and personal

2) Adequate theological education

3) Sound judgment and experience of life

4) Sufficient understanding of psychology, with the ability to recognize human woundedness and when to make referrals

5) One with whom you feel at ease

Directors should be engaged in their own spiritual direction, participating in regular peer supervision and group study, and seeking their own path to sainthood. Many individuals prefer to seek direction with someone of their own denomination or faith tradition. But as Janet Ruffing contends in The New Westminster Dictionary of Christian Spirituality, “The director does not impose his or her theology, opinions or spiritual path upon the one seeking direction, but rather tries to discover and support the ‘spiritual direction’ the Holy Spirit is already initiating in the directee’s life.”

Spiritual direction is offered individually as well as in small groups, and isolated or ongoing retreats are also common. Regardless of the mode, and unlike counseling, it is not common practice to engage in weekly spiritual direction. Rather, meeting for an hour once a month allows the directee time to engage in his or her own spiritual practice and to reflect upon the Spirit’s movement in everyday life.

The atmosphere fostered in spiritual direction is prayerful and reverent. The director and directee participate in a conversational process to collaboratively discern the work of the Spirit in the directee’s life. This discernment is grounded in a hermeneutic of Scripture and doctrine of the Christian tradition but does not ignore psychological processes. Directors ask facilitating questions, such as “What does it seem God is inviting you to in this situation or in your life? What does it seem God is asking of you?” Directors also draw upon prayer and the movement of the Spirit to guide the process and conversation. 

Spiritual direction can be a transformative practice at all stages of faith formation. Although spiritual directors often possess more theological or spiritual training, their goal is not to impose belief or dictate practice. Rather, they serve as co-witnesses to God’s work in the world, friends and co-journeyers in life. As in many forms of counseling and psychotherapy, the directees are responsible for their own growth, and the motivation for such resides in them rather than in the director. Many spiritual directors request a fee, while some accept a freewill donation. Still others offer their time with no expectation of anything in return.

Although the overall aim of both spiritual direction and counseling is to facilitate greater holistic well-being, their goals are distinct. Therefore, it is not uncommon for individuals to engage concurrently in counseling or psychotherapy and spiritual direction. Counselors may then engage in transferal rather than referral and continue to work with the client toward his or her psychosocial goals. As Ruffing contends in The New Westminster Dictionary of Christian Spirituality, transferal enables “both spiritual directors and therapists … to recognize their specific competencies and work carefully within their own disciplines.” In situations of transferal, the counselor can assist in finding a spiritual director to join the client in his or her faith journey.

Finding a spiritual director is not unlike finding a counselor in that it is a matter of “fit.” Trained and qualified spiritual directors can be located through retreat or direction centers, parish staff and religious communities. A wealth of resources are available online, including the “Seek and Find” function on the Spiritual Directors International website (SDIWorld.org). Through this site, you can search for a director based on geographic location and filter results according to religious/spiritual affiliation, institution and more. It is important to note, however, that membership in Spiritual Directors International is open to everyone. Furthermore, because practice is not restricted through licensure, locating an appropriately trained and credentialed director requires its own level of discernment and trust in the Holy Spirit.   

Conclusion

In recognizing that a client’s spiritual or religious beliefs are beyond one’s understanding or expertise, counselors need to perform their due diligence, carefully screening and selecting the appropriate professionals to whom they should refer. Being aware of the broader resources in your area not only helps the individuals, couples and families who come to you seeking help, but also increases interdisciplinary dialogue that can strengthen our communities in ways that would not otherwise be possible.

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

Jill L. Snodgrass is an assistant professor in the Department of Pastoral Counseling at Loyola University Maryland. She is a pastoral counselor and ordained minister in the United Church of Christ. Contact her at jlsnodgrass@loyola.edu.

Devlyn McCreight is a licensed clinical professional counselor who is currently pursuing his doctorate in pastoral counseling at Loyola University Maryland.

Michael R. McFee is an associate professor in the Counseling Psychology Department at Eastern University.

Letters to the editor: ct@counseling.org

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