Journal 1 Article Review

Therapists' Integration of Religion and Spirituality in Counseiing: A Meta-Analysis

Donald F. Walker, Richard L. Gorsuch, and Siang-Yang Tan

The authors conducted a 26-study meta-analysis of 5,759 therapists and their integration of religion and spirifuaiity in counseiing. Most therapists consider spirituaiity relevant to their iives but rareiy engage in spirituai practices or participate in organized religion. Marriage and famiiy thera- pists consider spirituaiity more reievant and participate in organized religion to a greater degree than therapists from other professions. Across professions, most therapists surveyed (over 80%) rareiy discuss spirituai or reiigious issues in training, in mixed sampies of reiigious and secular thera- pists, therapists' reiigious faith was associated with using religious and spiritual techniques in counseiing frequently, willingness to discuss reli- gion in therapy, and theoretical orientation.

Therapists' integration of religion and spirituality in counseling has beenevaluated in 26 studies of 5,759 psychotherapists from the fieldsof clinical and counseling psychology, psychiatry, social work, and pas- toral counseling. We suggest that it is now appropriate to perform a meta- analysis of the existing research. We discuss the relevance of religion and spirituality to counseling, review methods of integrating religion and spiri- tuality in coimseling, and conduct a meta-analysis of studies concerning thera- pists' integration of religion and spirituality into counseling.

Relevance of Religion and Spirituality to Counseling

In the area of multicultural theory, psychologists have continued to call for psychological treatments and interventions that are culturally sensitive and relevant and that integrate aspects of client culture into the counseling pro- cess (D. W. Sue & Sue, 1999; S. Sue, 1999). In addition, psychologists have increasingly recognized that religion and spirituality are relevant aspects of client diversity that psychologists should be able to recognize while treat- ing religious or spiritual clients with sensitivity (Ridley, Baker, & Hill, 2001; D. W. Sue, Bingham, Porche-Burke, & Vasquez, 1999).

Richards and Bergin (2000) have proposed that the integration of religious and spiritual culture in counseling is conceptually similar to the dynamics of more general multicultural counseling attitudes and skills previously advanced by other multicultural researchers (e.g., D. W. Sue & Sue, 1999). Richards and Bergin (2000) further suggested that multicultural competent attitudes and skills regarding religion and spirituality encompass several domains.

Donald F. Walker, Richard L. Gorsuch, and Siang-Yang Tan, Graduate School of Psychology, Fuller Theological Seminary. A portion of this research was presented at the 2001 annual meeting of the American Psychological Association, San Francisco. Correspondence concerning this article should be addressed to Donald F. Walker, Fuller Theological Seminary, Graduate School of Psy- chology, 180 N. Oakland Avenue, Pasadena, CA 91101 (e-mail: [email protected]).

Counseiing and Vaiues • October 2004 • Voiume 49 69

Among the domains of multicultiaral attitudes and skills most pertinent to this study are (a) an awareness of one's own cultural heritage, (b) respect and comfort with other cultures and values that differ from one's own, and (c) an awareness of one's helping style and how this style could affect clients from other cultural back- grounds. Hence, knowledge of religion and spirituality is an important element of therapists' multicviltural competency.

Religion and spirituality are important aspects of multicultural competency for therapists to consider given the religious culture in America. Researchers have found that more than 90% of Americans claim either a Protestant or Catholic religious affiliation (Keller, 2000), 40% of Americans attend religious services on a weekly basis, and more than two thirds of Americans consider personal spiritual prac- tices to be an important part of their daily lives (Hoge, 1996). Thus, it is important for counselors to understand how their own religious and spiritual culture may differ from that of the general populace and the clients whom they serve.

This meta-analysis has several aims. One purpose of this study was to examine via meta-analysis the spiritual and religious culture and values of counselors. We use this information to suggest ways in which therapists' religious cultures may differ from those of their clients and to explore how such differences might be con- structively approached in counseling. A second purpose of this study was to ex- plore via meta-analysis links between the personal religiousness of counselors and therapists and several counseling-related variables. We use this information to understand across studies how therapists' religiousness relates to their helping style with clients from varying religious and spiritual backgrounds.

Methods of Integrating Religion and Spirituality in Counseling

One issue that has been problematic when discussing methods of integrating reli- gion and spirituality in counseling has been agreeing on exactly what is being inte- grated. Pargament (1999), for example, noted that psychologists of religion rarely agree on specific definitions of religion and spirituality. However, on a broad level, religion has typically been defined as that which is more organizational, ritual, and ideologi- cal, whereas spirituality has typically been defined as that which is more personal, affective, and experiential (Pargament, 1999; Richards & Bergin, 1997). In this study, the same broad definitions will be used when referring to religion and spirituality.

Therapists have proposed several different methods of integrating religious and spiritual culture into counseling. According to Tan (1996), explicit integration refers to

a more overt approach that directly and systematically deals with spiritual or religious issues in therapy, and uses spiritual resources like prayer, Scripture or sacred texts, referrals to church or other religious groups or lay counselors, and other religious practices, (p. 368)

Tan noted that this approach to coimseling emphasizes both therapist and cli- ent spirituality and integrates counseling with some form of spiritual direction.

Another approach to integrating religion and spirituality in counseling is the implicit integration of religion or spirituality. Implicit integration is "a more covert approach that does not initiate the discussion of religious or spiritual is-

70 Counseling and Values • October 2004 • Volume 49

sues and does not openly, directly, or systematically use spiritual resources like prayer and Scripture or other sacred texts, in therapy" (Tan, 1996, p. 368). An ex- ample of implicit integration is basing therapeutic values on theistic principles from an organized religion. Implicit integration maybe the preferred mode of integra- tion for therapists who profess a religious faith or engage in spiritual practices but who are not trained in the explicit integration of religion and spirituality.

Shafranske (1996) conducted a review of training in explicit and implicit inte- gration. His review suggested that "education and training within the area of psy- chology and religion appears to be very limited" (p. 160) and that the majority of therapists never discuss religious or spiritual issues in their clinical training. Richards and Bergin (1997) noted that such therapists run the risk of practicing outside the boundaries of professional competence or imposing their own values on religious or spiritual clients. Shafranske (1996) suggested that most therapists' approach to the integration of religion and spirituality in psychotherapy was not based on graduate trairung in the area but centered primarily on the personal religious and spiritual experience of the therapist.

A third form of integration is intrapersonal integration, which refers to the manner in which a therapist uses his or her personal religious or spiritual experience in counseling (Tan, 1987). An example of intrapersonal integration is silently pray- ing for a client during counseling.

This study attempts to determine how therapists practice their religion and spiri- tuality and to determine the degree to which the personal religious faith of thera- pists is associated with the use of religion and spirituality in counseling. This is accomplished through the use of meta-analysis.

The Use of Meta-Analysis as a Statistical Technique

Although meta-analysis often involves aggregating results from experimental studies, it can also be used in aggregating correlational data, as was done in this meta-analysis. As Rosenthal (1991) explained, the only constraint in determining the relationship between two variables is that the relationship be of interest to the investigator. The investigator deterrrvines relationships between variables by obtairung an estimate of the effect size between two variables, which some studies do not provide along with their tests of significance (Rosenthal, 1991). In these instances, the test of sig- riificance that is provided (whether yj^, t, or F) is transformed to an r for the purpose of computing an overall averaged r across studies.

Hvmter and Schmidt (1990) noted that one criticism of the meta-analysis of correlations is that it typically provides a slightly downward bias in the esti- mate of population correlations. In practical terms, this is not problematic; if anything, such correlations are more conservative estimates of the relationship between two variables.

In the current meta-analysis, we considered several issues to be relevant. The first issue we considered was the personal religion and spirituality of therapists. As mentioned earlier, this information is used to determine how differ- ent the culture of counselors might be from their clients and, thus, how the need for respect for, and comfort dealing with, cultures other than one's own might present

Counseling and Values • October 2004 • Volume 49 71

in a counseling situation. A second issue we considered concerned therapists' personal religiousness and their use of explicit integration of religion and spiritu- ality in counseling. This information is used to inform how therapists' personal religiousness may relate to their helping styles with religious clients.

Finally, we made comparisons, where possible, between samples that were iden- tified as containing explicitly religious therapists and sample groups that may have contained a mix of secular and religious therapists. We also made comparisons between therapists from different professional backgrounds to understand how each of the multicultural competencies (respect for cultures other than one's own, one's helping style as a therapist) might be different across professions.

Method Literature Search

We identified studies for inclusion in the meta-analysis using literature searches in the PsycINFO and Dissertation Abstracts International databases using the search terms counseling and religion, counseling and spirituality, psychotherapy and religion, a n d psychotherapy and spirituality. We sought unpublished studies, such as unpublished doctoral dissertatior^, in order to reduce die "file drawer problem" identified by Rosenthal (1979), in which the meta-analysis indicates a higher effect size than actu- ally exists because studies with nonsigruJficant effects have not been located.

We identified 40 studies through the literature search. Of those studies, we elimi- nated six dissertations because they were not empirical. We eliminated three other empirical dissertations because they did not contain variables of interest. We elimi- nated a final dissertation because it was not available, and the author did not respond to an e-mail message that had been sent. We eliminated 2 published studies by explicitly Christian therapists (Ball & Goodyear, 1991; Worthington, Dupont, Berry, & Duncan, 1988) because they were methodologically different from the other studies, making it impossible to include them in the meta-analysis. Two studies (Bergin & Jensen, 1990; Jensen & Bergin, 1988) were of the same sample. We considered these to be 1 study. One study (Sorenson & Hales, 2002) was a new analysis of two samples already included in the total data set, so this study was reviewed but not included in the analyses. Thus, the final number of studies included in the analyses was 26.

Demographic Characteristics of the Total Sample

We aggregated the demographic characteristics of the total sample across stud- ies to describe the sample. Regarding professional backgrounds, clinical and coun- seling psychologists composed 44.15% of the total sample, explicitly Christian counselors 21.30%, marriage and family therapists 14%, social workers 5.85%, psychiatrists 4.32%, explicitly Mormon psychotherapists 3.54%, psychotherapists 2.77%, licensed professional counselors 1.82%, and pastoral counselors 1.71%. (Per- centages do not total 100 due to rounding.) With respect to gender, men composed 58.11% of the sample, and women composed 41.89% of the sample. The sample ranged in age from 22 to 89 years, with a mean age of 46.1. Only five studies re- ported the race of the therapist sample. The authors of those five studies estimated

72 Counseling and Values • October 2004 •Volume 49

the percentage of White therapists to be 83% to 95% (Bilgrave & Deluty, 1998,2002; Case & McMinn, 2001; Forbes, 1995; Sheridan, Bullis, Adcock, Berlin, & Miller, 1992).

Computation of Effect Size

First, we converted all relationships of interest to an r, and then we calculated a weighted overall averaged r by weighting each individual correlation by the sample size associated with each individual study. Second, we calculated the overall sig- nificance level of each correlation by the method of adding z scores. Following the technique proposed by Rosenthal (1991), we added z scores from samples and then divided the sum of the z scores by the square root of the number of studies. Third, we compared the significance of several correlations using Fisher's test of signifi- cance between independent correlations (Cohen & Cohen, 1983). We used appen- dixes from Cohen and Cohen to transform correlations to z scores. Then, we divided the difference between the z equivalents by the standard error to obtain a normal curve deviate. We used appendixes provided in Cohen and Cohen to obtain the p value for the significance test. Finally, we added the raw scores from some items of interest (such as religious denomination) across studies.

Results

Personal Religion and Spirituality of Therapists

Religious affiliations of therapists from mixed samples were provided in 18 studies of 3,813 therapists. The majority of therapists in these samples were Protestant (34.51%), Jewish (19.61%), or Catholic (13.89%). Religious denominations among therapists from different professional backgrovinds are presented in Table 1. Clinical and counseling psychologists were more likely to be either an agnostic (x̂ = 10.27, p < .005) or atheist (x̂ = 27.19, p < .005) when compared with marriage and fam- ily therapists but were not more likely to be either an atheist or agnostic when compared with social workers. Clinical and counseling psychologists were also more likely to endorse no religion than either marriage and family therapists (X̂ = 34.13, p < .0001) or social workers (x̂ = 7.98, p < .01).

Five studies (N = 1,738) of therapists from mixed samples and 2 studies (N = 762) of explicitly religious therapists reported frequency of therapists' participation in organized religion or church activities. Among therapists from mixed samples, 21.1% reported being inactive, whereas 44.8% reported being active. Among explicitly religious therapists, only 8.79% reported being inac- tive, compared with a majority (82.54%) who reported being active. With respect to professional background, more marriage and family therapists were active (59.58%, 2 studies, N = 438) than either secular clinical and counseling psy- chologists (39.75%, 5 studies, N = 1,122) or psychiatrists (32%, 1 study, N = 71). Psychiatrists also endorsed inactive (68%) more frequently than either clini- cal and counseling psychologists (54.63%) or marriage and family therapists (16.21%). Possible reasons for these findings may have been that 15% of the sample in Winston's (1991) study of marriage and family therapists was com- posed of pastoral counselors, as well as the fact that psychiatrists were repre- sented in only a small, single sample.

Counseling and Values • October 2004 • Volume 49 73

TABLE 1

Differences in Religious Denomination by Professional Background

Affiliation Protestant Jewish Catholic Atheist Agnostic No religion Other

Psychoiogists*

N

593 339 250 31 74

270 297

%

35.85 20.49 15.11 1.87 4.47

16.32 17.96

Marriage and Famiiy Therapists"

N

433 110 126

3 6

71 117

% 50.0 12.7 14.6 0.03 0.07 8.2

13.5

Sociai Workers'

N

109 56 32 3 6

27 39

%

40.1 20.6 11.8

1.1 2.2 9.9

14.3

Note. Percentages do not total 100 due to rounding. °Ten studies. ""Six studies. 'Three studies.

Six studies (JV = 1,678) were used to calculate frequency of personal spiritual practices (such as prayer or meditation). We observed large differences between therapists from mixed samples (4 studies, N=916) and explicitly religious (2 stud- ies, N = 762) therapists. Among therapists from mixed samples, 40.6% reported engaging in personal spiritual practices on a weekly or daily basis compared with 78.8% of explicitly religious tiierapists. Among therapists from mixed samples, 45.5% reported engaging in personal spiritual practices infrequently or never compared with orJy 9.1% of explicitly religious therapists.

Religion and Spirituality in Counseling

To determine how often therapists use religious or spiritual techniques in counseling, we added responses and then averaged them across eight stud- ies (total N = 2,253). Four studies (N = 1,102) of therapists from mixed samples reported on the number of therapists who had previously used a religious or spiritual technique in therapy. The majority of therapists from mixed samples (66.6%) reported using prayer in therapy; 64.1% reported using religious language, metaphors, and concepts in therapy; and a minority (44.4%) reported using scripture in therapy.

Four studies (N = 1,037) reported explicitly religious therapists' frequency of using spiritual or religious techniques with religious clients rather than the percentage of those therapists who had used a technique before. Among explicitly religious therapists, forgiveness was used in 42.2% of therapy cases, use of scripture/teaching of biblical concepts in 39.2%, confrontation of sin in 32.6%, and religious imagery in 18.2% of therapy cases.

Prayer is a spiritual technique that has been studied in several ways among ex- plicitly religious therapists. Three studies (N = 1,097) reported that 73.6% of explic- itly religious therapists prayed for their clients outside of session. Five studies (N= 1,372) reported therapists' frequency of in-session prayer with clients. In those five studies, therapists used in-session prayer in 29.1% of therapy cases.

We calculated separate overall averaged rs for therapists from mixed samples and explicitly religious therapists to determine the relationship between thera-

74 Counseling and Values • October 2004 • Volume 49

pists' personal religious faith and therapists' frequency of use of religious and spiritual techniques in counseling. Authors of the studies that examined therapists' use of religious and spiritual techniques in counseling typically summed a list of individual religious and spiritual techniques and then cor- related that scale with a self-report measure of either religious attitudes or religious behaviors. The overall averaged r among therapists from mixed samples (using six studies, N = 873) was .24, p < .0002. The correlation among explicitly religious therapists was higher, overall averaged r = .41, p < .0001.

We also calculated separate overall averaged rs for therapists from different professional backgrounds to determine the relationship between therapists' per- sonal religious faith and use of spiritual techniques in counseling. The overall averaged r for marriage and family therapists was .12, p = .005. The correlation among clinical psychologists was higher, overall averaged r = .30, p < .001.

We conducted a series of tests of the difference between correlations using Fisher's comparison of r (Cohen & Cohen, 1983). The correlation between personal faith and therapists' use of spiritual techniques among explicitly religious therapists was significantly higher than the same correlation among therapists from mixed samples, p < .0001. Only one study (Forbes, 1995) com- puted a correlatiori between training in religious and spiritual issues and use of spiritual techniques in therapy (r = .38). This correlation was not statisti- cally significantly different from the correlation between personal faith and use of spiritual techniques among explicitly religious therapists {p = .12). Fi- nally, the correlation between personal religious faith and use of spiritual tech- ruques among marriage and family therapists in mixed samples was compared with the same correlation among clinical psychologists from mixed samples. This correlation was significantly higher for clinical psychologists {p = .004).

Finally, we calculated the frequency with which therapists from mixed samples discussed religion and spirituality issues during training using four studies {N = 1,156). The majority of therapists (82%) reported that they never or rarely discussed religious or spiritual issues in training, 13.6 % stated that they sometimes did, and 4.3% reported they discussed them often.

Relationship of Personal Religion to Counseling-Related Variables

We calculated the relationship between therapists' personal religiousness and opermess to discussing religious issues in counseling using an overall aver- aged r. The overall averaged r among therapists from mixed samples (3 stud- ies, N = 216) was equal to .37, p < .02, compared with an overall averaged r of .39, p = .007, using all 4 studies, and with .40 in the Jones, Watson, and Wol- fram (1992) study of religious therapists. These correlations were not statisti- cally different. Finally, we calculated an overall averaged r between the personal religious faith of the therapist and therapist theoretical orientation among thera- pists from mixed samples (5 studies, N = 1,474). This correlation was equal to .25, p < .001. (As noted earlier, Sorenson & Hales, 2002, performed a reanalysis of two data sets already included in the meta-analysis. As part of an analysis of covariance including other variables, they found that religious therapists trained at secular programs were significantly more likely, F[l, 396] = 19.82,

Counseling and Values • October 2004 "Volume 49 75

p < .001, to use explicit religious and spiritual interventior\s thari were reli- gious therapists trained at explicitly religious training programs.)

Discussion

One issue we examined in this study was the religious and spiritual cultural heritage of psychotherapists. The results confirm that the religious and spiri- tual cultural heritage of psychotherapists differs from that of the average American. Indeed, the majority of therapists from mixed samples were affili- ated with a religious denomination but were largely inactive within organized religion. This contrasts sharply with the general U.S. population, because approximately 40% of Americans attend church on a weekly basis (Hoge, 1996). In addition, although the majority of psychotherapists claim that spirituality is relevant to them, most engage in personal spiritual practices infrequently, whereas approximately two thirds of Americans consider spiritual practices such as prayer an important part of their daily lives (Hoge, 1996). Thus, if a therapist comes from a religious and spiritual cultural heritage that differs from the client's, he or she should consider the potential impact of their cul- tural differences on the course of treatment.

Therapists' religious cultural heritage may be an especially salient issue for clinical and counseling psychologists, who were more likely to endorse athe- ism, agnosticism, or no religion than either marriage and family therapists or social workers. Among Americans claiming a religious affiliation, the majority of them (56.6%) are Protestant, followed by Catholic (37.8%), with people from Jewish, Muslim, Buddhist, or other religious backgrounds composing the remaining 5.5% of religious people in America (Keller, 2000). Thus, religious cultural differ- ences with regard to denomination (as well as the beliefs and practices associ- ated with being in a denomination) between client and therapist are likely to exist, particularly for clinical and counseling psychologists.

Clinical and counseling psychologists who find it difficult to understand the cultural heritage of clients who practice their spirituality within the context of an organized religion may wish to consult with explicitly religious therapists on such therapy cases. Explicitly religious therapists were more similar to the ma- jority of Americans, as measured by previous polls (e.g., GaUup & Lindsay, 1999), with respect to religious affiliations and personal spiritual practices. Thus, ex- plicitly religious therapists may be a particularly valuable resource for therapy cases with religious clients when the consulting therapist does not have a good understanding of the cultural heritage of the client.

It is clear from the results that personal religiousness on the part of both explic- itly religious therapists and therapists from mixed samples was associated with being able to integrate religion and spirituality into several aspects of counseling (e.g., the use of spirituality, being willing to discuss religious issues, even choice of theoretical orientation). Given the lack of training regarding the integration of religion and spirituality into counseling, it seems that most integration of reli- gion and spirituality in covmseUng occurs through intrapersonal integration as a result of therapists' own religious or spiritual experience. As such, it seems that

76 Counseling and Values • October 2004 "Volume 49

explicitly religious therapists (who engage more frequently in religious and spiri- tual practices), rather than nonreligious therapists, would be better equipped in some Instances to provide religious and spiritual interventions for clients.

One danger in providing religious and spiritual interventions is that the lack of formal training to supplement therapists' personal religious or spiri- tual experience creates a risk of therapists imposing their own values or applying religious and spiritual interventions inappropriately. Given that therapists do use their own personal religious and spiritual experience in integrating religion and spirituality into counseling, additional training, when offered, should address how to make appropriate use of one's own reli- gious and spiritual experience when integrating religion and spirituality into counseling, as well as training regarding clients' religious backgrounds and the appropriateness of various religious and spiritual interventions with clients from differing religious backgrounds.

Training need not occur solely in the classroom but could also be effectively provided in the context of supervision or consultation on therapy cases involv- ing religious and spiritual issues. There are a few explicitly religious graduate training programs in clinical psychology that have been accredited by the Ameri- can Psychological Association. It is hoped that graduates of such programs would be equipped to provide appropriate consultation and/or supervision. However, the efficacy of these training programs in helping therapists integrate religion and spirituality into counseling above and beyond drawing on their own per- sonal religious and spiritual experiences has yet to be documented.

The results indicate that many therapists are already making use of reUgion and spirituality in therapy. Therapists from mixed samples reported a much larger percentage using religious and spiritual techniques in therapy than the percent- age of explicitly religious therapists reported using religious or spiritual tech- niques in therapy. However, studies of explicitly religious therapists reported how often they used a technique rather than the number of participants in the sainple who had ever used a technique at aU, as was done in studies using mixed samples of therapists. Thus, the different research questions make direct comparisons between therapists difficult. However, one noteworthy trend across both groups of therapists is that scripture and prayer were spiritual techniques that were com- monly used by both groups. This finding suggests that prayer and scripture, in particular, are religious and spiritual interventions that therapists should receive training on for counseling.

Limitations of the Current Study and Suggestions for Future Research

The first limitation of the study is that we analyzed two major variables that had varying degrees of relatedness. Rosenthal (1991) referred to this common limitation of meta-analysis studies as the problem of heterogeneity of method. As did Glass (1978), Rosenthal also referred to this as the "apples and oranges issue" and suggested that they are good things to mix when at- tempting to generalize to fruit.

Counseling and Values • October 2004 •Volume 49 77

One variable was the diverse professional background of the therapists in the meta-analysis. The analyses indicated differences among therapists in the areas of religious denomination and organized religion and in the relation- ship between personal religious faith and use of spirituality in therapy. It would have been preferable to make explicit comparisons of therapists from differ- ent professional backgrounds for every analysis. This limitation was unavoid- able, because some major primary studies grouped therapists together and some analyses did not have a sufficient number of representatives from vari- ous professions to allow for explicit comparisons.

Other variables with varying degrees of relatedness were the religious and spiritual variables used in the analyses. We aggregated each of these indi- vidual variables to represent global religious and spiritual constructs, but we might have obtained larger effect sizes had there been a greater degree of specificity between independent and dependent variables in the analyses.

A second limitation of the study was the possible sampling bias of therapists from mixed samples. Because most studies designated as being a mixed sample did not explicitly state whether they were sampling therapists from explicitly religious programs along with therapists from secular programs, it is difficult to know just how religious the therapists in some of these samples were. This was less problematic when authors reported the number of explicitly religious therapists in their sample (e.g., Kochems, 1983; Winston, 1991). In such cases, it would have also been desirable to split the samples and analyze them sepa- rately, but the primary studies themselves have not done so.

A final limitation was the use of small subsamples of the data to perform analy- ses. This is a common practice when examining different independent and dependent variables in meta-analyses of correlations, because not all studies using correlations will use the same independent or dependent variables in the analysis. However, it would have been desirable to have more studies available on which to do some of the analyses, particularly when attempting to compare religious and secular therapists and therapists from different professional back- grounds. The small number of published studies is informative because it leads to the conclusion that the field could clearly benefit from additional research regarding therapists' integration of religion and spirituality in counseling.

Most important, we suggest that studies are needed that relate meaningful variables to therapists' use of religion and spirituality in counseling with a variety of religious clients. Therapists' frequency and competency of use of spiritual techniques need to be assessed, rather than whether a therapist has used a technique, as some studies have done. Such precision will allow fur- ther refinement and training for therapists who see religious and spiritual clients. Only two studies (Forbes, 1995; Sorenson & Hales, 2002) have exam- ined the relationship of any training variables to therapists' ability to inte- grate aspects of clients' religion and spirituality in therapy. Therapist variables associated with the integration of religion and spirituality in counseling have also yet to be identified. As these and other variables are identified, clients who participate in organized religion can look forward to counseling services that actively and effectively use their religious culture.

78 Counseling and Values • October 2004 • Volume 49

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