PERSONAL COUNSELING THEORY

Read: Tan: Chapters 17 - 20

Tan, S-Y (2022). Counseling and Psychotherapy: A Christian Perspective (2nd ed.). Baker Academic: GrandRapids, MI. ISBN: 9781540962904.

Chapters 17

Christian Theology in Christian Counseling

A Biblical Perspective on Human Nature and Effective Counseling and Psychotherapy

A significant contemporary development in clinical practice is the integration of religion or spirituality with psychotherapy (see, e.g., Aten & Leach 2009; Aten, McMinn, & Worthington 2011; Cashwell & J. S. Young 2020; Dowd & Nielsen 2006; Frame 2003; Gill & Freund 2018; R. S. Jones 2019; Griffith & Griffith 2001; G. Miller 2003; W. R. Miller 1999; J. M. Nelson 2009; Paloutzian & Park 2013; Pargament 1997, 2007; Pargament, Mahoney, & Shafranske 2013; Plante 2009; Richards & Bergin 2004, 2005, 2014; Sears & Niblick 2014; Shafranske 1996; Sorenson 2004; Sperry 2011; Sperry & Shafranske 2005; Stewart-Sicking, Fox, & Deal 2020).

More specifically, the integration of Christian faith and psychotherapy, or Christian therapy, has also witnessed tremendous growth in recent years (see N. T. Anderson, Zuehlke, & Zuehlke 2000; Appleby & Ohlschlager 2013; Benner 1998; Clinton & Ohlschlager 2002; Clinton, Hart, & Ohlschlager 2005; Collins 2007; Greggo & Sisemore 2012; Hawkins & Clinton 2015; E. L. Johnson 2017; I. F. Jones 2006; Knabb, Johnson, Bates, & Sisemore 2019; Malony & Augsburger 2007; McMinn 1996; McMinn & Campbell 2007; McRay, Yarhouse, & Butman 2016; Pugh 2008; J. C. Thomas 2018; Worthington et al. 2013; see also R. S. Anderson 1990; S. L. Jones & Butman 2011; Sbanotto, Gingrich, & Gingrich 2016; Stevenson, Eck, & Hill 2007; Tan 2011a; J. S. Thomas & Sosin 2011; Yarhouse & Sells 2017).

The final four chapters of this book focus specifically on a Christian approach to therapy that is Christ centered, biblically based, and Spirit filled (see Tan 2001b, 2012; also Tan 1996c). In this chapter, a biblical perspective on human nature and effective therapy is discussed. It emphasizes the crucial and central role of Christian theology or Scripture in Christian counseling (Tan 1991, 2001b; see also Collins 1993; Crabb 1977, 1987; Farnsworth 1996; Hurley & Berry 1997a, 1997b; E. L. Johnson 2007, 2017; Porter 2010a, 2010b; Welch & Powlison 1997a, 1997b).

Christian Theology in Christian Counseling: Approaches to Integration of Christian Faith and Psychology

Although there are various approaches to Christian counseling, the role of Christian theology based on Scripture in Christian counseling is crucial and central (Tan 2001b). Such integration of Christian faith or Christian theology and counseling can be conceptualized while using many different models. Brian Eck (1996) has provided a helpful summary of twenty-seven models of integration of Christian theology and psychology (including counseling and psychotherapy) that can be organized into three major paradigms: the nonintegrative paradigm, the manipulative paradigm, and the nonmanipulative paradigm. The following is his succinct description of these three major paradigms of integration:

The Non-Integrative Paradigm does not seek integration of the data but rather builds its understanding of God’s truth on one discipline alone. The Manipulative Paradigm seeks to integrate the data of both disciplines, but the data of one discipline must be altered before becoming acceptable to the other discipline. The final paradigm, the Non-Manipulative Paradigm, accepts the data from both disciplines directly into the integrative process. Each paradigm contains certain processes that define the method for how the data of each discipline will be integrated. The Non-Integrative Paradigm contains only the Rejects Process; the Manipulative Paradigm contains both the Reconstructs Process and the Transforms Process; and the Non-Manipulative Paradigm utilizes the Correlates Process and the Unifies Process. (Eck 1996, 103).

Another way of summarizing the various models or paradigms of integration is to describe them in terms of four basic approaches (see Carter 1996; Carter & Narramore 1979): Christianity against psychology (usually held by biblically militant and conservative Christians), Christianity of psychology (usually held by those with more liberal theological views), the parallels model or approach (Christianity and psychology are seen as equally important but essentially separate fields), and Christianity integrates psychology. Lawrence J. Crabb (1977) more simply described these four basic approaches to integration thus: (1) nothing buttery (psychology is unnecessary and irrelevant because only the Bible is needed to deal with human problems and needs), (2) tossed salad (equal and mixable), (3) separate but equal, and (4) spoiling the Egyptians (using whatever concepts or techniques from secular psychology that are consistent with Scripture or the Bible, with the Bible having final authority).

Another description of five major views on the relationship of psychology and Christianity is the following (see E. L. Johnson 2010): (1) a levels-of-explanation (scientific) view (Myers 2010), (2) an integration view (S. L. Jones 2010a), (3) a Christian psychology view (Roberts & Watson 2010), (4) a transformational psychology view (Coe & Hall 2010a), and (5) a biblical counseling view (Powlison 2010). A levels-of-explanation view approaches psychology and theology as separate but equally important fields of disciplines. An integration view takes psychology seriously but submits it ultimately to scriptural truth, the Bible properly interpreted. A Christian psychology view grounds psychology in Scripture and in biblical and historical theology. A transformational psychology view grounds psychology in spiritual formation or as psychology in the Spirit. Finally, a biblical counseling view uses the Bible as the foundational and essential basis for counseling (see Tan 2012, 147).

The approach to Christian counseling that I propose and describe in this book is consistent with the Christianity-integrates-psychology approach (Carter & Narramore 1979) or the spoiling the Egyptians (Crabb 1977) approach to integration of Christian faith and psychology (including counseling and psychotherapy). However, it is also consistent with a recent emphasis on going beyond integration to develop a distinctly Christian psychology that is more substantially grounded in biblical and historical theology and ultimately in Scripture itself, as Eric Johnson (2007) has advocated and described (see also Roberts & Watson 2010). The role of Scripture or Christian theology is therefore central to my description of a Christian counseling approach that is Christ centered, biblically based, and Spirit filled (Tan 2001b; see also Tan 1991). Thus, Scripture has ultimate authority because it is the inspired Word of God, which does deal with the major issues and problems of human beings, especially when properly interpreted in thematic and extended application contexts (Crabb 1977, 1987; see also Farnsworth 1996; Porter 2010a, 2010b). The Bible is comprehensive, even if it is not exhaustive (cf. S. L. Jones 1996), regarding human beings and their functioning and dysfunctioning, and therefore it is foundational for a truly Christian psychology and Christian counseling and soul care (E. L. Johnson 2007, 2017). Basic Christian theology must be carefully understood, with the best of biblical interpretation, and then applied to the context of Christian therapy, thus providing the biblical basis of Christian counseling for people helpers (Collins 1993; see also Collins 2007; B. Kellemen & Forrey 2014; H. Lambert 2016). My approach to Christian counseling resonates most with the integration (S. L. Jones 2010), Christian psychology (Roberts & Watson 2010; see also E. L. Johnson 2007), transformational psychology (Coe & Hall 2010a), and biblical counseling (Powlison 2010) views on the relationship of psychology and Christianity (see also Dueck & Lee 2005; Entwistle 2015; Hathaway & Yarhouse 2021; McMinn & Phillips 2001; Moriarty 2010; Worthington 2010). It builds bridges with biblical counselors and appreciates all that is truly biblical (see Monroe 1997). It emphasizes personal or intrapersonal integration (i.e., a person’s own appropriation of psychological and spiritual experience, including one’s spirituality in Christ) as the most foundational area of integration (Tan 2001b), with the three major areas of integration (Malony 1995) being principled (theoretical-conceptual and research), professional (clinical or practice), and personal (intrapersonal, including spirituality). Five approaches to counseling and Christianity have also been described (see Greggo & Sisemore 2012), following the five views of psychology and Christianity (E. L. Johnson 2010).

Cameron Lee (2020) has also emphasized the personal or intrapersonal area of integration by advocating for an understanding of integration as a matter of personal integrity. He proposed developing the core identity of Christian therapists as peacemakers, and peacemaking as the central motif of such Christ-centered integration, following the Beatitudes of Jesus (Matt. 5:3–11). As peacemakers, therapists will therefore cultivate the clinical virtues of hope, humility, compassion, and Sabbath rest.

A more recent development in the integration of psychology and Christianity goes beyond the traditional five views (E. L. Johnson 2010) to approaches that are more personal (see Sorenson 1996; Sorenson et al. 2004), embodied (M. Neff & McMinn 2020), relational (Sandage & Brown 2018; Sandage et al. 2020), and community-based—with extended cognition among one another that enhances religious community and true spiritual formation and is not individualistic (Strawn & Brown 2020). Brad Strawn, Earl Bland, and Paul Flores (2018) have described three waves of integration as apologetics, model building, and empirical validation; the more recent fourth wave of clinical integration focuses on experiential learning and clinical application, with greater cultural and theological diversity (see Strawn 2020).

This fourth wave of clinical integration (Strawn, Bland, & Flores 2018) includes or is consistent with the more recent personal, embodied, relational, and community-based approaches to integration; it goes beyond abstract and more idealistic or theoretical views of integration, emphasizing that integration is a personal and relational experience within and between actual people; therefore, experiential learning in a clinical context, with cultural and theological diversity, is crucial (see also Sandage & Brown 2018; Sorenson 1996). The need to be more specific about the theological tradition or perspective from which one is attempting integration has been recently underscored by several authors who have focused on the uniqueness and specificity of the integration task, asking which Christianity and which psychology are being integrated (see Bland & Strawn 2014a; 2014b; Strawn, Wright, & Jones 2014; see also Dueck 2002; Dueck & Reimer 2009; J. H. Wright, Jones, & Strawn 2014). Brad Strawn and his colleagues in particular have pointed out that the Christianity or evangelical Christianity that is often assumed in integration efforts with psychology is not monolithic: usually a Reformed theological perspective is being used, leaving out other evangelical perspectives such as Strawn’s Wesleyan Holiness or Nazarene tradition (see Strawn, Wright, & Jones 2014; see also Bland & Strawn 2014a; 2014b; R. Wright, Jones, & Strawn 2014). It is therefore essential that we specify which Christian tradition or theology we are attempting to integrate with which specific psychology, and that we more clearly talk with each other (Dueck 2002).

The Wesleyan tradition is also well known for the view that four sources of authority make up the “Wesleyan quadrilateral” (Outler 1985): Scripture, reason, tradition, and experience, with the highest authority traditionally given to Scripture. However, honest and humble dialogue with all four sources of authority or truth is essential for sound integration to take place. For example, science and neuroscience are crucial and should be seriously considered and included in attempts at integration of a specific mode of Christianity with a particular psychology (see W. S. Brown 2004; W. S. Brown & Strawn 2012). More recently, Brad Strawn and Warren Brown (2020) have described how extended cognition, based on a theory of mind and neuroscience, can augment religious or Christian community and enhance, or “supersize,” Christian life or spiritual formation that is relational and community-based, not individualistic.

Similarly, Megan Neff and Mark McMinn (2020), in a unique daughter-father collaboration, recently described a fresh look at Christianity in the therapy room, consistent with the fourth wave of clinical integration, titling their book Embodying Integration. They mainly use a postmodern perspective that emphasizes the dynamic rather than the static, process rather than content, mystery rather than certainty, concrete rather than abstract, being rather than doing, questioning rather than answering, journeying rather than arriving, and accepting rather than changing (to paraphrase Joshua Knabb’s endorsement of their book). Neff and McMinn make explicit the following premises they hold in embodying integration:

(1) Integration happens between people. More specifically, integration happens in conversation. . . . (2) Integration is lived out in real lives, embodied in the person of the psychotherapist, which means it is more desirable to train integrators than to attempt mastering, articulating, or communicating a discipline known as “integration.” (3) Integration is embedded in social and cultural contexts and therefore will have some variation to it. (4) All truth is God’s truth. This is not to say that everything is true, but rather that every true thing comes from God. Christianity and psychology both belong in the conversation, and each can help transform our understanding of the other. (5) Ideas are important. Ideas explored in interaction with particular contexts are particularly meaningful. (2020, 22)

These more recent perspectives, models, or approaches to the integration of Christianity and psychology (see also Callaway & Whitney 2022; Hathaway & Yarhouse 2021) certainly go beyond the traditional five views of integration (E. L. Johnson 2010; see also Greggo & Sisemore 2012). I am deeply thankful for these recent approaches, which have helped us to be more humble, relational, personal, and communal as well as more embodied in our integration endeavors. They resonate with my emphasis on the personal or intrapersonal dimension of integration that includes one’s spirituality (see Tan 2001b, 2012), not in an individualistic sense, as is often emphasized in Western Christian spirituality, but more community based and oriented to church or body life, as others such as Barton (2014), Bolsinger (2004), and Wilhoit (2008) have also underscored in describing spiritual formation as if the church mattered, and how the church or community of God transforms lives (see also Strawn & Brown 2020). However, I must honestly express my concern that we continue to be biblically based and grounded in Scripture as our ultimate authority, with the best of biblical interpretation and a keen awareness of our own denominational or Christian tradition. This requires humility and prayerful dependence on the Holy Spirit, who is our teacher par excellence of all truth, including psychotheological truth in integration, and necessitates being in community with Christian scholars and others.

My own theological perspective or Christian tradition from which I engage in integration is evangelical Christianity, leaning more toward Reformed theology as well as a charismatic orientation, in what I describe as being “biblically charismatic.” My own clinical psychology training and experience have been mainly in broad-based cognitive behavior therapy that is more relational, existential, and spiritually or biblically based (see Tan 1987a, 2007b, 2013a), more recently including Christian approaches to mindfulness-based cognitive behavior therapies (see Tan 2011b; see also Rosales & Tan 2016, 2017; Wang & Tan 2016).

Basic Christian theology usually covers the following major topics, which Gary Collins (1993) has briefly described and applied to Christian counseling: bibliology (the doctrine of Scripture), theology proper (the doctrine of God the Father), Christology (the doctrine of God the Son), pneumatology (the doctrine of God the Holy Spirit), anthropology (the doctrine of human beings), hamartiology (the doctrine of sin), soteriology (the doctrine of salvation), ecclesiology (the doctrine of the church), angelology (the doctrine of angels), and eschatology (the doctrine of the future or last things). These major Christian doctrines are usually explained in some detail in systematic theology books (see, e.g., Grudem 2020). Much more work must be done in understanding and applying such Christian theology to Christian therapy contexts, especially with more theological depth and sophistication (see J. R. Beck 2006; see also Holeman 2012; E. L. Johnson 2007, 2017; B. Kellemen & Forrey 2014; H. Lambert 2016; Powlison 2003).

A crucial topic covered in previous chapters on the major approaches to therapy concerns their perspective on human nature. In Christian therapy, a biblical perspective on human nature is also a critical and foundational topic. Much integrative work in this area of biblical anthropology has been recently published, with some substantial and helpful attempts at theological and psychological integration (e.g., Balswick, King, & Reimer 2016; J. R. Beck & Demarest 2005; W. S. Brown, Murphy, & Malony 1998; Brugger and the Faculty of Institute for the Psychological Sciences 2008; Corcoran 2006; Green 2008; L. W. Hoffman & Strawn 2009; Lints, Horton, & Talbot 2006; Puffer 2007; Vitz, Nordling, & Titus 2020; see also Cortez 2016, 2017; O. D. Crisp & Sanders 2018; T. M. Crisp, Porter, & Ten Elshof 2016; Farris 2020; Kilner 2015; LaPine 2021).

A Biblical Perspective on Human Nature

A biblical perspective on human nature (biblical anthropology) focuses on the essential or unique characteristics of human beings, based on Scripture (see Puffer 2007, 45). Biblically based views of human nature vary even among Christian theologians and therapists. For example, an important topic in biblical anthropology that has received much attention and debate in recent years is the nature of the soul, and even whether a human being has a soul (see, e.g., N. Murphy 2006). The more traditional views assume some form of dualism in a human being, with body-soul or body-mind composition, or even trichotomism with body, soul, and spirit composition (see N. Murphy 2006, 95–98). An alternative view that has recently been gaining support is nonreductive physicalism (N. Murphy 2006), which assumes that a human being’s essential nature is basically synonymous with their physical body (including the brain), and thus there is no separate soul of the person, with “soul” referring instead to the capacity to relate to God (see also W. S. Brown, Murphy, & Malony 1998; W. S. Brown & Strawn 2012; Corcoran 2006; Green 2008; Jeeves & Brown 2009). However, this debate continues (see, e.g., T. M. Crisp, Porter, & Ten Elshof 2016), with strong criticisms of the nonreductive physicalism view (which attempts to take neuroscience seriously in a theological context) by other well-known Christian scholars who espouse a more traditional or nuanced dualistic view of the human being as having a body and a soul, or being a body-soul in composition (see J. R. Beck & Demarest 2005, 203–209; J. W. Cooper 1989; Green & Palmer 2005).

Whether one accepts a more traditional or nuanced dualistic view of the human being or espouses a nonreductive physicalism view of human nature, it is still crucial to have a basic biblical perspective on human nature to guide the process and practice of Christian counseling. Keith Puffer has described a modest proposal of seven essential biblical assumptions about human nature and summarized them in the following statement: “Humans are created beings fashioned into God’s image. Fallen with a sinful nature and striving to find meaning, people are also redeemable, dwellable by God’s Spirit, and transformable for God’s purposes” (2007, 46).

He provides further implications of the following seven essential biblical assumptions about human beings or human nature: they are (1) created beings, (2) fashioned in the image of God, (3) fallen with a sin nature, (4) striving to find meaning, (5) redeemable, (6) dwellable by the Spirit of God, and (7) transformable for God’s purposes (Puffer 2007, 47–53).

In proposing and describing a biblical model for effective lay counseling some years ago, I included the following summary of a basic view of humanity or human nature from a biblical perspective:

Basic psychological and spiritual needs include needs for security (love), significance (meaning/impact), and hope (forgiveness).

Basic problem is sin—but not all emotional suffering is due to personal sin.

Ultimate goal of humanity is to know God and have spiritual health.

Problem feelings are usually due to problem behavior and, more fundamentally, problem thinking—however, biological and demonic factors should also be considered.

Holistic view of persons—all have physical, mental/emotional, social, and spiritual dimensions (Tan 1991, 50–51; see also Tan & Scalise 2016, 62–63).

This basic view of human nature from a biblical perspective is not an exhaustive or even comprehensive treatment of the vast and complex topic of biblical anthropology. It is an attempt to describe five basic biblical assumptions of human nature that have special relevance to effective Christian counseling (see Tan 1991, 34–39, 50–51; see also Tan & Scalise 2016, 40–44, 62–63), which will now be covered in more detail.

First, the basic psychological and spiritual needs of human beings include the needs for security (love) and significance (purpose) (Crabb 1977) and for hope (forgiveness) (Adams 1973). The basic human needs for security and significance have been rephrased by Crabb as “deep longings in the human heart for relationship and impact” (1987, 15), which can only be fully met in the context of a personal relationship with Jesus Christ as one’s Lord and Savior. Such longings or needs will not be completely satisfied while one lives in a sinful, fallen world that is imperfect; hence, complete fulfillment of them in the Lord can only be experienced in heaven, which is coming (Rev. 3:12; 21:2). However, these needs can be substantially satisfied by surrendering our self-protective defenses and depending more fully on Jesus Christ to empower us to live our lives according to his will, including being involved with a caring community of believers in a local church context. Although the basic psychological and spiritual needs of human beings can be described in various ways, depending on one’s theoretical and theological viewpoint, such basic human longings include the needs for security (love/relationship), significance (purpose/impact), and hope (forgiveness).

Second, from a biblical perspective, humanity’s basic problem is sin. All human beings have sinned and therefore are fallen people (Rom. 3:23), yet they have been created in the image of God (Gen. 1:26–27), with a freedom or capacity to choose (Deut. 30:19; Josh. 24:15). Disobeying God’s moral laws as revealed in Scripture and believing the satanic deception or lie that we can handle our own lives and fulfill our basic needs and longings without God—these mistakes underlie most psychological or emotional problems that do not have obvious organic bases (Crabb 1977; see also Adams 1970). However, this does not mean that all emotional suffering is due to personal sin or even the sins of others. Sometimes emotional pain is simply part of living in a fallen, sinful, imperfect world. Paradoxically, emotional anguish can also at times have nothing to do with sin at all; it may instead result from the process of being perfected by God into deeper Christlikeness (i.e., sanctification) and thus from obedience to God’s will rather than sinful disobedience. Jesus himself experienced deep anguish and emotional and spiritual suffering in the garden of Gethsemane (see Grounds 1976) as he struggled with the Father’s will for him to go to the cross and die for sinful humanity, in order to save us (Matt. 26:36–39; Mark 14:32–36; Luke 22:40–44). Yet he never sinned (Heb. 4:15). We must therefore discern and differentiate between sin-induced emotional suffering and the anguish that is sometimes part of the process of growing as a Christian into deeper Christlikeness and obedience to God’s will.

There are “mystical” aspects of the spiritual life in Christ that include processes and experiences not easily comprehended, such as the “dark night of the soul,” according to St. John of the Cross (cf. Isa. 50:10). The dark night is not evil or sinful but ultimately good (see Coe 2000; see also S. Burns 2020). Richard Foster has described such an experience thus:

The “dark night” . . . is not something bad or destructive. . . . The purpose of the darkness is not to punish or afflict us. It is to set us free. . . .

What is involved in entering the dark night of the soul? It may be a sense of dryness, depression, even lostness. It strips us of overdependence on the emotional life. The notion, often heard today, that such experiences can be avoided and that we should live in peace and comfort, joy and celebration, only betrays the fact that much contemporary experience is surface slush. The dark night is one of the ways God brings us to a hush, a stillness, so that He can work on inner transformation of the soul. . . . Recognize the dark night for what it is. Be grateful that God is lovingly drawing you away from every distraction so that you can see Him. (1978, 89–91)

I have thus previously written about the need for Christian counselors and therapists to better understand and thus more appropriately help clients who are experiencing mystical aspects of the spiritual life in Christ, such as the dark night of the soul:

From a psychological perspective, Christian psychologists need to have a better acquaintance with such processes of the spiritual life as the dark night of the soul . . . so that they do not naively or prematurely attempt to reduce all painful symptoms, but rather to appropriate their meaning first. This will require not only psychological assessment skills but spiritual wisdom and discernment as well. Sometimes there is no easy solution or therapy or healing, but to trust God and His grace to help people grow through such deepening and painful spiritual experiences. The best therapy then is to provide understanding, support, and much prayer. (Tan 1987b, 37)

In the literature on psychology and religion, more attention has recently been given to the phenomenon of spiritual struggle, which includes experiences such as the dark night of the soul (Pargament et al. 2005; see also Exline 2013; Murray-Swank & Murray-Swank 2013), and in spiritually integrated psychotherapy (Pargament 2007). In this context, it is crucial to help clients deal with and overcome spiritual bypass, referring to a process in which a client will use their spirituality or religious and spiritual values, beliefs, and practices as a defense to avoid painful experiences or threatening issues in their lives (Fox, Cashwell, & Picciotto 2017; see also Fox et al. 2020).

Third, the ultimate goal of humanity is to know God and enjoy him forever; hence, spiritual health is primary. The end goal in life for a Christian is to obey God’s will and grow in maturity in Christ, to become more like Christ (Rom. 8:29). This may involve suffering at times, but God has promised to provide sufficient grace and to empower us in our weakness (2 Cor. 12:7–9). Although mental and physical health are worthwhile and acceptable goals to achieve, they are always secondary for the Christian and subordinate to the end goal of spiritual health and maturity in Christ. The absence of emotional pain, happiness at all costs, is therefore not the ultimate goal of life on earth for the Christian. Biblical perspectives on suffering (e.g., see Tan 2019a, 2019b), including what C. Stephen Evans (1986) has called “the blessings of mental anguish,” need to be affirmed. Evans has also noted that “the primary goal of a Christian counselor is not to help people become merely ‘normal,’ but to help them love God with all their hearts, minds and souls” (1986, 29). The ultimate goal of life on earth and also of Christian counseling should therefore be holiness, not temporal happiness, and spiritual health or wholeness, not just mental or physical health (see Grounds 1976, 105–111).

Fourth, a biblical perspective on human nature assumes that problem feelings are usually due to problem behavior (cf. Gen. 4:3–7) and, more fundamentally, to problem thinking (John 8:32; Rom. 12:1–2; Eph. 4:22–24; Phil. 4:8). Crabb (1977) has emphasized that at the root of nonorganically caused mental and emotional problems are unbiblical, erroneous basic assumptions or beliefs, what William Backus (1985) has called “misbeliefs” (see also Backus & Chapian 1980), reflecting a Christian approach to cognitive therapy or rational emotive behavior therapy. However, this does not mean that problem feelings are always due to problem behavior and problem thinking. Problem feelings can at times be due to biological or physical factors, even if no known organic cause can be found, since current knowledge of such biological factors is limited but ever expanding. Medical or psychiatric help, where appropriate, should be sought. Problem feelings (as well as thoughts and behaviors) can also sometimes be due to demonic activity (demonization), whether demonic oppression or possession, in which case when properly discerned, prayer for deliverance may be necessary (e.g., Bufford 1988; MacNutt 1995). Some helpful criteria (though not foolproof) for discerning the presence of the demonic versus mental illness include the following: the afflicted person’s strong, negative reaction to hearing the name “Jesus” (or the reading of Scripture or the singing of hymns); a foreboding or almost overwhelming sense of evil on the part of the therapist; the afflicted person’s history of involvement with the occult and/or cults; and possibly an olfactory criterion involving a smell of sulfur or rotten eggs associated with the afflicted person. These are not definitive differential diagnostic criteria for demonization versus mental illness. They should be used in consultation with other pastors or Christian counselors experienced in deliverance ministries and pastoral care and counseling, as well as with much prayer and dependence on the Holy Spirit and his gift of discerning of spirits (1 Cor. 12:10).

In a broader sense and from a biblical perspective, counseling and psychotherapy can be viewed as involving spiritual warfare because they inevitably deal with good and evil, including the demonic. In this context, Marguerite Shuster (1987) has emphasized the need for agape love, humility, weakness, and dependence on the Lord’s grace and power on the part of the counselor or therapist in order to conquer evil with good.

The need to keep a good balance in focusing not only on problem thinking but also on all three major areas of human experience—feelings, behavior, and thoughts—has been emphasized by Collins (1976). Similarly, Crabb (1987) has stressed the need to attend to all four major circles or dimensions of a person’s functioning: the personal, rational, volitional, and emotional areas. Nevertheless, the crucial role of problem thinking and problem behavior in the development of problem feelings must not be lost or negated.

Fifth and finally, a biblical perspective on human nature assumes a holistic view of people with physical, mental-emotional, social, and spiritual dimensions (cf. Luke 2:52). As Jay Adams has observed, a client’s problem (e.g., depression or anxiety) must be viewed in the context of all areas of their life, and biblical restructuring should also involve all these areas in what he calls “total structuring”: (1) church, Bible, prayer, witness; (2) work, school; (3) physical health, exercise, diet, sleep; (4) marriage, sex; (5) finances, budget; (6) family, children, discipline; (7) social activities, friends; and (8) other (e.g., reading) (see 1973, 409–412).

A similar comprehensive but secular approach to viewing human functioning and dysfunctioning is the multimodal therapy perspective advocated by Arnold Lazarus, discussed in chapter 11 of this book. Lazarus (1989, 2008) described seven major dimensions of human personality functioning, summarized as an individual’s BASIC ID (or basic identity): Behavior, Affect, Sensations, Images, Cognitions, Interpersonal relationships, Drugs/Biology. The BASIC ID does not specifically include or focus on the crucial spiritual dimension of life. Christian counselors can add S for the spiritual dimension so that it now reads the BASIC IDS (see Tan 1991, 39); or as Jeffrey Bjorck has suggested, they can use the seven dimensions of the BASIC ID to assess the spiritual realm and one’s experience of God (2007, 145).

Basic Principles of Effective Counseling and Psychotherapy: A Biblical Perspective

I have further proposed and described fourteen basic principles of effective counseling and psychotherapy from a biblical perspective, which are evidence-based as much as possible. They are also based on empirical research and counseling theories that are consistent with biblical views. Here is my summary of the fourteen principles:

1. The Holy Spirit’s ministry as counselor is crucial; depend on the Spirit.

2. The Bible is a basic and comprehensive (not exhaustive) guide for counseling.

3. Prayer is an integral part of biblical counseling.

4. The ultimate goals of counseling are maturity in Christ and fulfilling the Great Commission.

5. The personal qualities of the counselor are important, especially spiritual ones.

6. The client’s attitudes, motivations, and desire for help are important.

7. The relationship between counselor and client is significant.

8. Effective counseling is a process involving exploration, understanding, and action phases, with a focus on changing problem thinking.

9. The style or approach in counseling should be flexible.

10. Specific techniques or methods of counseling should be consistent with Scripture; cognitive-behavioral ones may be especially helpful, with qualifications.

11. Cultural sensitivity and cross-cultural counseling skills are required.

12. Outreach and prevention skills in the context of a caring community are important.

13. Crisis counseling is important.

14. Awareness of limitations and referral skills are also important. (Tan & Scalise 2016, 62–63)

These fourteen basic principles of effective counseling and psychotherapy, from a biblical perspective and also as evidence-based, will now be covered in more detail (see Tan & Scalise 2016, 46–62).

First, the Holy Spirit’s ministry as counselor or comforter is crucial in effective Christian counseling (Tan 1999b). As Adams (1973) has emphasized, there are always at least three persons involved in every situation of counseling: the client, the counselor, and the Holy Spirit. Prayerful dependence on the Holy Spirit and the Spirit’s work as “Counselor” is essential in effective Christian counseling (cf. John 14:16–17). The Christian counselor must be filled with the Holy Spirit (Eph. 5:18) and depend on the Spirit’s power, gifts, truth, and fruit in order to help clients in a Christ-centered, biblically based, and Spirit-led way (Tan 1999b; see also Pugh 2008).

Second, the Bible is the basic guide for dealing with problems in living (cf. 2 Tim. 3:16–17). It is a comprehensive (though not exhaustive) guide for counseling because it speaks meaningfully to human problems and needs when it is carefully interpreted in terms of its contents, categories, implications, and images as well as its extended applications to the complex problems with which people struggle (Crabb 1987; see also Adams 1973). Believers therefore need not only as accurate and appropriate interpretation of the Bible as possible (exegesis and hermeneutics), but also practical application to life and its difficulties for it to function as a basic guide for counseling. The Christian counselor must have at least some basic knowledge of Scripture and theology because Christian theology is foundational for effective Christian counseling (Collins 1993; Hurding 1992; I. F. Jones 2006; see also Collins 2007; E. L. Johnson 2007, 2017; B. Kellemen & Forrey 2014; Kruis 2013; H. Lambert 2016; P. A. Miller 2013; K. R. Miller & Miller 2014, 2017). However, the Bible is not an exhaustive guide for counseling. Hence, theories and techniques from secular therapy can be used in Christian counseling insofar as they do not contradict Scripture or biblical values. This view affirms that all truth is God’s truth, that truth is unified, and that God’s general revelation and common grace allow much of God’s truth to be discovered even by those who are not Christians, such as through good research. However, ultimate authority is still given to Scripture.

Third, prayer is an integral part of effective Christian counseling that is biblically based (cf. James 5:16). The Christian counselor can also use prayer in varied ways, such as praying for the client before and in between counseling sessions and silently during counseling sessions. Prayer can also be used explicitly during counseling sessions when the Christian counselor prays aloud with the client. Informed consent from the client must be obtained before using spiritual resources such as prayer and Scripture in counseling sessions (see Tan 1996b).

Fourth, the ultimate goal of Christian counseling is to make disciples or disciplers of clients (see Collins 1976). With informed consent from clients, Christian counselors can sensitively point clients to Christ and thus help to fulfill the Great Commission (Matt. 28:18–20). Collins (1976) has therefore described Christian counseling as “discipleship counseling” (see also N. T. Anderson 2003). Crabb (1977) has similarly emphasized that the basic goal of Christian counseling is to help free people to better worship and serve God by guiding them toward maturity in Christ (Rom. 8:29).

Fifth, the personal qualities of the Christian counselor are important for effective Christian counseling. For example, Christian counselors need to have qualities such as goodness (goodwill or love), knowledge of God’s Word, and wisdom in applying it in practical ways (Rom. 15:14; Col. 3:16) (Adams 1973). They may be especially gifted for counseling ministries with spiritual gifts such as encouragement (Rom. 12:8) (see Tan 1999b). Christian counselors must also be spiritually mature to be effective in helping clients with their problems in living (cf. Gal. 6:1–2). The fruit of the Spirit, manifested especially in agape love (Gal. 5:22–23; 1 Cor. 13), is also essential in the Christian counselor, who must be, at minimum, warm, empathic, and genuine in relating to clients.

Sixth, the client’s attitudes, motivations, and desire for help are also crucial factors for determining the outcome of counseling and psychotherapy (see Collins 1976). For example, according to research findings from the Vanderbilt Psychotherapy Study, the process variable that most consistently predicted the outcome of counseling or therapy was the extent of client involvement in therapy (Gomes-Schwartz 1978). More specifically, clients who were not hostile or mistrustful and who actively participated in their therapy showed more therapeutic changes compared to clients who were defensive, withdrawn, or unwilling to be actively involved in their therapy (see Gomes-Schwartz 1978, 1032; see also Bohart & Tallman 2010; Bohart & Wade 2013; Duncan et al. 2010; Norcross & Lambert 2019; Norcross & Wampold 2019; Wampold & Imel 2015).

Seventh, the relationship between the counselor and the client is another significant variable for determining the outcome of counseling and psychotherapy. Robert Carkhuff (1971) has emphasized the importance of good rapport and communication in the relationship between the counselor and the client for effective counseling. He describes six “core conditions” for therapeutic change: the facilitative conditions of (1) empathy (understanding), (2) respect (caring or warmth), and (3) concreteness (being specific), plus the action conditions of (4) genuineness (being real), (5) confrontation (telling it like it is), and (6) immediacy (what’s really going on between the two of you). Ephesians 4:15, in a similar vein, emphasizes speaking the truth (similar to concreteness, immediacy, confrontation, and genuineness) in love (similar to respect or warmth, empathy, and genuineness). More-recent research on empirically supported therapeutic relationships (ESRs), or psychotherapy relationships that work, has shown that therapeutic alliance, cohesion in group therapy, goal consensus, empathy, positive regard and affirmation, and collecting and delivering client feedback are demonstrably effective; and congruence/genuineness, real relationship, emotional expression, cultivating positive expectations, promoting treatment credibility, managing countertransference, and repairing alliance ruptures are probably effective as general elements of the therapy relationship, mainly provided by the therapist (see Norcross & Lambert 2019, 632). With regard to methods of adapting therapy to patient characteristics, culture (race/ethnicity), religion/spirituality, and patient preferences are demonstrably effective; and reactance level, stages of change, and coping styles are probably effective (see Norcross & Lambert 2019, 632).

Eighth, effective counseling is a process involving exploration, understanding, and action phases that unfold cyclically. It therefore requires the counselor to explore and understand the client and the presented problems before undertaking specific courses of action to help the client (see Carkhuff 1971; G. Egan 1986). Crabb (1977) has expanded the three major phases of exploration, understanding, and action in the counseling process into a seven-stage model of effective biblical counseling: (stage 1) identify problem feelings, (stage 2) identify problem behavior, (stage 3) identify problem thinking, (stage 4) teach and clarify biblical thinking, (stage 5) secure commitment, (stage 6) plan or carry out biblical behavior, and (stage 7) identify Spirit-controlled feelings.

Ninth, directive, or nouthetic, counseling is an important part of Christian counseling, but the style or approach taken in Christian counseling and therapy should be flexible. Nouthetic counseling is directive and involves caring confrontation to bring about client change in a biblical way, as developed by Jay Adams (1970, 1973), and is an important part but not the whole of Christian counseling. Biblically based Christian counseling is more appropriately based on parakaleō and paraklēsis rather than only on noutheteō and nouthesia, Greek words found in the New Testament that are most relevant to counseling. Biblical counseling therefore includes not only the nouthetic, directive and confrontational approach but also the parakaleō components such as encouraging, supporting, and comforting (J. D. Carter 1975). The specific style or approach that a Christian counselor takes in helping clients should be flexible and appropriate to the specific client with a particular problem. First Thessalonians 5:14 provides wise biblical guidance that supports such sensitive flexibility in counseling: “We urge you, brothers and sisters, warn those who are idle and disruptive, encourage the disheartened, help the weak, be patient with everyone.” David Carlson (1976) has also observed from Scripture that Jesus’s style of relating was flexible, ranging from his prophetic, confrontational style to his priestly, accepting style, with his pastoral style in between, adjusted to help the person to whom he was relating.

Tenth, there is flexibility with regard to specific techniques or therapeutic methods to be used in counseling and therapy, but they should be consistent with Scripture. A certain technical eclecticism in the use of specific therapy techniques is acceptable provided that the Scriptures are used as the ultimate screening device for deciding whether to accept or reject specific therapeutic interventions (cf. 1 Thess. 5:21). Whatever is deemed unbiblical or antibiblical should be rejected, but whatever is seen as consistent with Scripture, even if it is not in the Bible, can be used. Cognitive-behavioral and behavioral techniques can be especially helpful to many clients across a range of clinical problems, as already covered in chapters 11–12 of this book. However, a biblical approach to, and critique of, cognitive-behavioral interventions should still be used (see Tan 1987a). Mark McMinn and Clark Campbell (2007) have described a more comprehensive Christian approach to therapy called integrative psychotherapy, which integrates behavioral, cognitive, and interpersonal models of therapy within a Christian theological framework. Integrative therapies, including positive psychotherapy, have eclectically used many helpful therapeutic interventions and techniques that are evidenced-based (see chap. 15 of this book; also Norcross & Goldfried 2019); Christian therapists have indeed used evidence-based interventions (e.g., see Worthington et al. 2013). Evidenced-based interventions should still be consistent with biblical truth, morality, and ethics (see Tan 1987a).

Eleventh, effective Christian counseling requires cultural sensitivity and cross-cultural or multicultural counseling skills. American society has become even more pluralistic, diverse, and multicultural in recent years. Christian counseling, as well as counseling and therapy in general, must be culturally sensitive and use cross-cultural or multicultural counseling skills to be effective in helping clients from diverse backgrounds (see, e.g., Ridley 2005; D. W. Sue et al. 2019; Diana Sue & Sue 2008; for Christian perspectives, see also Augsburger 1986; Dueck & Reimer 2009; Hesselgrave 1984; Ridley 1986; Uomoto 1986; Tan 1999a; Yang 1996), and to overcome subtle microaggressions (see, e.g., D. W. Sue et al. 2019; yet also Lilienfeld 2017, 2020; Lui & Quezada 2019; M. T. Williams 2020a, 2020b), as well as overt and systemic racism.

Twelfth, outreach and prevention skills in the context of a caring community or the local church are important in effective Christian counseling. Jeffrey Prater (1987) made the following six proposals, originally for lay Christian counselors to be trained in interventions that go beyond individual counseling; they are also relevant to professional Christian counselors and therapists: (1) Christian counselors should be trained to assess the role of environmental stressors (e.g., poverty, unemployment, racism, sexism, and lack of social support) in the development and maintenance of emotional problems. (2) Christian counselors should be trained in the techniques of community outreach and empowerment. (3) Christian counselors should be trained in cultural awareness and sensitivity. (4) Christian counselors should be trained to be aware of and to make use of existing support systems and services within churches. (5) Christian counselors should be trained in skills to develop new support systems within the church where needed (e.g., prevention-oriented seminars on topics such as stress management, parenting skills, and conflict resolution). (6) Christian counselors should be trained to communicate more actively and regularly with other leaders involved in outreach ministries of the church so that a coordinated package of ministries can be established.

Thirteenth, since counseling, whether lay or professional, often involves crisis events faced by clients, crisis counseling is important in effective helping. Eric Scalise has described six steps in the ABCs of crisis intervention for effectively addressing a crisis situation in counseling: (1) Achieve a connection with the other person. (2) Break down the problem. (3) Commit to a plan of action. (4) Document the interaction. (5) Explain the plan of action. (6) Follow up as soon as possible (see Tan & Scalise 2016, 58–60).

Fourteenth and finally, awareness of limitations and referral skills is also important in effective Christian counseling. Every counselor or therapist has limitations and needs to be aware of them in order to skillfully and sensitively make appropriate referrals of clients to other professionals (e.g., other therapists or counselors, lawyers, psychiatrists, physicians, financial consultants) who can better help such clients because of their expertise. Some examples of counseling situations that may require referring clients to other professionals include those involving clients who are severely disturbed or suicidal, need medical or psychiatric help, have serious financial needs or legal problems, show extremely aggressive behavior, use drugs or alcohol in excessive and harmful ways, or want to see another therapist (see Collins 1976, 113). Referrals should always be made in a sensitive and supportive way by the counselor to connect the client with an appropriate professional who can be of further help to them.

The crucial and essential role of Christian theology in Christian counseling and therapy has been emphasized in this chapter. A biblical perspective on human nature, with five basic assumptions, and a biblical approach to effective counseling that is based on evidence as much as possible, with fourteen basic principles that I have previously described in the context of lay Christian counseling (Tan & Scalise 2016)—these have been summarized and updated in this chapter for application to Christian counseling and therapy as a whole, whether professional or lay.

Recommended Readings

Beck, J. R., & Demarest, B. (2005). The human person in theology and psychology: A biblical anthropology for the twenty-first century. Grand Rapids: Kregel.

Collins, G. R. (1993). The biblical basis of Christian counseling for people helpers. Colorado Springs: NavPress.

Crabb, L. J. (1987). Understanding people: Deep longings for relationship. Grand Rapids: Zondervan.

Crisp, T. M., Porter S. L., & Ten Elshof, G. A. (Eds.). (2016). Neuroscience and the soul: The human person in philosophy, science, and theology. Grand Rapids: Eerdmans.

Greggo, S. P., & Sisemore, T. A. (Eds.). (2012). Counseling and Christianity: Five Approaches. Downers Grove, IL: IVP Academic.

Hathaway, W. L., & Yarhouse, M. A. (2021). The integration of psychology and Christianity: A domain-based approach. Downers Grove, IL: IVP Academic.

Johnson, E. L. (2007). Foundations for soul care: A Christian psychology proposal. Downers Grove, IL: IVP Academic.

Johnson, E. L. (2010). Psychology and Christianity: Five views. Downers Grove, IL: IVP Academic.

Johnson, E. L. (2017). God and soul care: The therapeutic resources of the Christian faith. Downers Grove, IL: IVP Academic.

Neff, M. A., & McMinn, M. R. (2020). Embodying integration: A fresh look at Christianity in the therapy room. Downers Grove, IL: IVP Academic.

Sandage, S. J., & Brown, J. K. (2018). Relational integration of psychology and theology: Theory, research and practice. New York: Routledge.

Stevenson, D. H., Eck, B. E., & Hill, P. C. (Eds.). (2007). Psychology and Christianity: Seminal works that shaped the movement. Batavia, IL: Christian Association for Psychological Studies.

Tan, S. Y., & Scalise, E. T. (2016). Lay counseling: Equipping Christians for a helping ministry (revised and updated). Grand Rapids: Zondervan.

Chapters 18

Christian Faith in Clinical Practice

Implicit and Explicit Integration

Christian faith in clinical practice, as a specific example of religion or spirituality in clinical practice (Tan 1996c), refers to integration in the therapy room (M. E. L. Hall & Hall 1997; see also Eck 2002). Such integration has also been called professional integration (Tan 2001b), the practical integration of theology and psychology (N. T. Anderson, Zuehlke, & Zuehlke 2000). It involves the actual conducting of Christian counseling and psychotherapy that is Christ centered, biblically based, and Spirit led (Tan 2001b). As noted in the preceding chapter, this area of Christian counseling and therapy has witnessed significant growth and development in recent years, as has the more general area of religiously oriented and spiritually oriented therapy, especially in the last two decades or so. Relatively contextualistic approaches in the third wave of behavior therapy and cognitive behavior therapy—including acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), and dialectical behavior therapy (DBT)—have also recently emphasized mindfulness and acceptance, which have spiritual roots in Zen Buddhism (Hayes et al. 2006) as well as Christian contemplative religious or spiritual traditions (see Tan 2007b, 2011b; see also Rosales & Tan 2016, 2017; Wang & Tan 2016).

Implicit and Explicit Integration in Christian Therapy

Christian therapy has been described as consecrated counseling with the following distinctives: “Counseling is most truly Christian when the counselor has a deep faith; counsels with excellence; holds a Christian worldview; is guided by Christian values in choosing the means, goals, and motivations of counseling; actively seeks the presence and work of God; and actively utilizes spiritual interventions and resources within ethical guidelines” (Bufford 1997, 120). Two major models of professional integration in the actual clinical practice of Christian therapy are implicit and explicit integration, which can be described as two ends of a continuum: “Implicit integration . . . refers to a more covert approach that does not initiate the discussion of religious or spiritual issues and does not openly, directly, or systematically use spiritual resources. . . . 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” (Tan 1996c, 368). A Christian therapist will practice implicit or explicit integration or move along the continuum between implicit and explicit integration, depending on the needs and problems of the client as well as the training, inclination, and personality of the Christian therapist. It is crucial to notice that both implicit and explicit integration are equally substantial and important. Intentional and prayerful integration is the critical factor, whether it involves implicit or explicit integration or both. It should be conducted in dependence on the Holy Spirit, in a professionally competent, ethically responsible, and clinically sensitive way, with clear informed consent from the client (Tan 2001b; see also Tan 2012).

Implicit Integration in Christian Therapy

Implicit Integration in Christian Therapy

The Christian therapist who practices implicit integration in Christian therapy does not initiate discussion of religious or spiritual issues with the client and does not openly, directly, or systematically employ spiritual resources or interventions such as prayer and Scripture in therapy with the client. Implicit integration is a more covert approach to integrating Christian faith in clinical practice. However, it is still a crucial and substantial approach that is intentional and prayerfully dependent on the Holy Spirit for guidance and healing grace as clients are helped in therapy. The Christian therapist using an implicit integration approach will still be silently praying for the client and be authentic in showing agape love to the client. This therapist will thus reflect biblical values and convictions without imposing them on the client or explicitly discussing such religious issues in a verbal way with the client.

Implicit integration is especially helpful and appropriate when the Christian therapist is helping clients who are not believers or Christians and who are not interested in discussing spiritual or religious issues or using spiritual resources such as prayer and Scripture. It is also appropriate in counseling with Christian clients who are not interested in a more explicit approach to Christian therapy, whether they are presently in active rebellion against God, experiencing a significant spiritual struggle, simply feeling indifferent or cold toward God and the spiritual life, or prefer a more quiet, overt personal spirituality. However, as therapy progresses, such clients may become more interested in discussing spiritual or religious issues in a more direct and open way, including the possible use of spiritual resources such as prayer and Scripture, in which case the Christian therapist may move in the continuum to a more explicit integration approach in therapy.

Implicit integration in Christian therapy may also be more easily adopted by Christian therapists who practice from psychodynamic and psychoanalytic perspectives, since these approaches to therapy require the therapist to be more of a “blank slate” and nondirective. Explicit integration, on the other hand, may be more easily adopted by Christian therapists who practice from cognitive-behavioral and humanistic-existential perspectives, since these approaches to therapy are consistent with the therapist assuming a more directive stance (see I. R. Payne, Bergin, & Loftus 1992).

C. Jeffrey Terrell (2007) has challenged the definition of implicit integration presented thus far, following the original formulation of implicit and explicit integration that I provided in an earlier work (Tan 1996c). Terrell instead describes an intentional incarnational integration approach in relational psychodynamic psychotherapy (see also S. A. Rogers 2007), which is usually viewed as implicit integration, according to my original formulation (Tan 1996c). However, it can be conceptualized as “explicit” integration in another sense because the therapist’s use of the therapeutic relationship as a catalyst for bringing about deeper change in the client’s relational patterns is very intentional. Terrell states:

In making this argument, I realize that I am blurring the boundaries of explicit and implicit integration. . . . It is “explicit” in its avowal that our patient is worthy of love. It is “explicit” in its awareness of imperfection and failure in him or her. It is “explicit” in its unflinching description of his or her attempts to manipulate the world. It is “explicit” in its acceptance of our patient, despite his or her worst, most humiliating experiences. In this way, intentional and incarnational integration is being practiced, whether implicit or explicit in its verbal expression. (2007, 162)

Terrell therefore emphasizes that such an intended incarnational integration approach in relational psychodynamic Christian therapy can be conceptualized as “explicit” as well as implicit integration. He concludes: “When we engage relationally, our patients believe we get them. We hear the worst and still accept them. Modeling the gospel story, our work is incarnational. . . . It is redemptive, integrative, and intentional . . . , ‘explicit’ even when it doesn’t involve the direct use of scriptural texts or in-session prayer” (Terrell 2007, 164). In a similar vein, Steven Rogers (2007) has emphasized that a focus on the process and the here and now within therapy can itself be described as a powerful spiritual intervention in object relations psychotherapy, a psychodynamic approach to therapy. This process orientation includes skills such as the therapist acknowledging their own errors while conducting therapy with the client, and the therapist using personal feelings in appropriate self-disclosure during a therapy session. Rogers views this process orientation and focus on the here and now within a therapy session as a highly spiritual intervention because it reflects God’s way of relating to human beings and creates a sacred space for clients to develop deeper understanding of themselves, others, and God.

Explicit Integration in Christian Therapy

Explicit integration is a more overt approach to integrating Christian faith into clinical practice. It views the spirituality of both the therapist and the client to be foundational for effective therapy as well as for growth and wholeness. It integrates psychological therapy with spiritual guidance or direction to some extent, in the context of therapy (Tan 1996c; see also Tan 2003c). The Christian therapist who practices explicit integration in Christian therapy will more verbally, directly, and systematically deal with spiritual issues in therapy and use spiritual resources such as prayer, Scripture, referrals to church or other support groups or lay counselors, and other religious practices.

Explicit integration in Christian therapy should be conducted in a clinically sensitive, ethically responsible, and professionally competent way; this guards against potential misuse by overenthusiastic therapists who may unethically impose their religious values and spiritual interventions on clients (Tan 1996c). Several ethical guidelines are available for the appropriate practice of explicit integration in Christian therapy (see, e.g., Tan 2003c). They include the following three basic practices proposed by Alan Nelson and William Wilson (1984), who state that it is ethical for therapists to use their religious faith in therapy if (1) they are dealing with clinical problems that can be helped by religious or spiritual interventions, (2) they are not imposing their own religious beliefs and values on the client and thus are working within the client’s belief system, and (3) they have obtained informed consent from the client to use religious or spiritual resources and interventions as part of a clearly defined therapy contract with the client.

Sidebar 18.1: Three Aspects of Explicit Integration

(see Tan 1996c)

1. Using religious and spiritual resources in therapy

2. Dealing with spiritual issues in therapy

3. Fostering intrapersonal integration and the development of spirituality in the therapist and the client

In the initial intake interview, a Christian therapist therefore needs to openly and sensitively discuss with the client how they would like to deal with religious or spiritual issues, if at all, so that the therapist can then decide whether to use an explicit or implicit integration approach in therapy. The therapist can ask helpful questions in the intake interview, such as these: “What is your religion or religious affiliation, if any?” and “Are religious or spiritual issues and resources such as prayer important for you and me to address in our therapy sessions?” If the client is not interested in dealing with religious or spiritual issues in therapy, then the therapist needs to respect the client’s wishes. If the client expresses an interest in having a more explicit integration approach in therapy, then the therapist can proceed to obtain informed consent from the client, preferably in written form. The therapy contract clearly agreed upon, with full and free informed consent from the client, will therefore include open and direct discussion of religious or spiritual issues and the use of spiritual resources and interventions such as prayer and Scripture. It will also include the goals set by the client for therapy. However, if the therapist does not feel adequately trained or experienced in using an explicit integration approach in therapy, then the therapist should refer the client to another Christian therapist who may be more experienced in conducting explicit Christian therapy (Tan 1996c).

Implicit and explicit integration are not two mutually exclusive models for integrating Christian faith in therapy. They are actually two ends of a continuum of integration. A Christian therapist’s approach can range from being implicit to explicit in addressing religious or spiritual issues and using spiritual resources in therapy. The therapist can also move along the continuum with the client at various stages of the therapy or even during a specific session, depending on the needs and openness of the client. The therapist must respond to the client in an appropriate, sensitive, and empathic way. As Terrell (2007) has emphasized, a more relational psychodynamic approach to therapy, while relatively more implicit, can also be considered to have “explicit” features since it is very intentional in its Christian integration approach, which is essentially incarnational in nature, even if it is not always verbal in dealing with religious issues.

Explicit integration in Christian therapy has various components. Three major aspects of explicit integration are these: (1) using religious and spiritual resources in therapy, (2) dealing with spiritual issues in therapy, and (3) fostering intrapersonal integration and the development of spirituality in the therapist and the client (see Tan 1996c).

Explicit Integration: Use of Religious and Spiritual Resources in Therapy

A major component of explicit integration is the direct, open, and systematic use of religious and spiritual resources in therapy. There are many examples of such resources (see, e.g., Aten & Leach 2009; Aten, McMinn, & Worthington 2011; Pargament 2007; Plante 2009; Richards & Bergin 2005; Sperry & Shafranske 2005; see also Cashwell & Young 2020; Gill & Freund 2018; R. S. Jones 2019; Pargament, Mahoney, & Shafranske 2013; Sears & Niblick 2014; D. Walker, Courtois, & Aten 2014; D. Walker & Hathaway 2013), but three main ones are prayer, Scripture, and referral to religious groups (Tan 1996c; see also Appleby & Ohlschlager 2013; Knabb, Johnson, Bates, & Sisemore 2019; Sbanotto, Gingrich, & Gingrich 2016; J. C. Thomas 2018; J. C. Thomas & Sosin 2011; Worthington et al. 2013).

Prayer

Prayer is a major spiritual resource or intervention, often used in explicit integration. It can be described simply as communing with God, but it also refers to other ways of experiencing or focusing on God (C. B. Johnson 1987). It includes meditative (waiting and worshiping in God’s presence), ritualistic (involving the use of rituals), petitionary (making specific requests), and colloquial (conversational and relational, with gratitude) prayer (Poloma & Pendleton 1989, 1991), as well as intercessory (asking on behalf of others, e.g., for their healing and blessing) prayer (McCullough & Larson 1999). A specific form of prayer has been termed “holy name repetition,” and Christian examples include “Lord Jesus Christ, Son of God, have mercy on me”; “Lord Jesus, have mercy”; or simply “Jesus”; all as variants of the Jesus Prayer (see Oman & Driskill 2003; see also Vasquez & Jensen 2020). Richard J. Foster (1992) in fact describes twenty-one types of prayer. They help us in moving inward (seeking the transformation we need), moving upward (seeking the intimacy we need), and moving outward (seeking the ministry we need). Many Christians have memorized the different types of prayer as consisting of Adoration, Confession, Thanksgiving, and Supplication (including both petition for oneself and intercession for others): ACTS. Thus different types of prayer can be used in Christian therapy with a client (e.g., quiet, meditative, or contemplative prayer; general prayer aloud with the client; specific prayer aloud with and for the client; inner-healing prayer or prayer for healing of memories). A Christian therapist can also use prayer at various times, such as before, during, or after the therapy session; at the beginning or at the end of the therapy session; or any other time connected with the therapy session.

The use of Christian contemplative prayer in psychotherapy refers to a type of prayer that focuses one’s full attention on relating to God in an open, passive, nondefensive, and nondemanding way (see Finney & Malony 1985a, 1985b, 1985c). Such contemplative prayer, or any other form of prayer, should not be used simply as a therapeutic technique or coping strategy for managing anxiety more effectively (Finney & Malony 1985b), but should be used only if spiritual development is also a goal of therapy. Prayer should be viewed as an end in itself and not just as a tool, technique, or strategy (see Hunsinger 2006). Prayer is to be a way of life for the Christian in relationship with God (C. B. Johnson 1987). Prayer is ultimately “the transforming friendship” with God (Houston 1989), in which we find our heart’s true home in loving, intimate relationship with God (Foster 1992). Relational prayer therefore comes before petitionary prayer (Crabb 2006). Prayer can also be described as a “tree of life” that unifies Christian spirituality, with five major models of prayer: conversation, relationship, journey, transformation, and presence (Chase 2005).

Two major traditions of prayer have been described: apophatic, mainly wordless prayer, and kataphatic, using mainly words in prayer (see Knabb & Frederick 2017, 24–25; see also H. Egan 1978). Apophatic prayer has the following characteristics (see Lane 1998): in time spent with God, sitting in silence, letting go of using language or words, having an attitude of awe and mystery, developing a loving attitude, letting go of control, emptying oneself, having an attitude of surrender and humility and vulnerability, letting go of all expectations, and “praying with your eyes shut” (E. H. Peterson 1989, 84). On the other hand, kataphatic prayer has these characteristics (see Lane 1998): in time spent with God, using language, feelings, sensations, thoughts and images, Scripture, metaphor, and “praying with your eyes open” (E. H. Petersen 1989, 84).

Joshua Knabb and Thomas Frederick (2017) have developed an eight-week Christian contemplative prayer program for helping Christians with chronic worry that richly draws from Scripture and the practices of the early desert Christians and others throughout church history, with a focus on contemplative prayer for overcoming chronic worry and anxiety. Their program includes helpful daily exercises (for at least twenty minutes) and forms of contemplative prayer: the serenity prayer, Ignatian contemplation, the Jesus Prayer, centering prayer, and the welcoming prayer. Such a Christian meditation and contemplative prayer approach that is directly God-centered (see Knabb 2021; also Trammel & Trent 2021) has received some preliminary empirical support for its effectiveness with repetitive negative thinking (Knabb, Vasquez, Garzon, et al. 2020; see also Knabb et al. 2018), recurrent worry (Knabb, Frederick, & Cumming 2017), daily stress (Knabb & Vasquez 2018), and with shifting from trauma-based ruminations to ruminating on God (Knabb, Vasquez, & Pate 2019).

Inner-healing prayer, or healing of memories, is a specific type of prayer that can be defined as “a form of prayer designed to facilitate the client’s ability to process affectively painful memories through vividly recalling those memories and asking for the presence of Christ (or God) to minister in the midst of this pain” (Garzon & Burkett 2002, 42). Fernando Garzon and Lori Burkett have reviewed four major models of healing of memories developed by David Seamands (1985), myself (Tan 1996c), Leanne Payne (1991), and Edward M. Smith (2005), the founder of Theophostic Ministry, describing their commonalities as well as differences. They noted that the history of healing of memories can be traced back to Agnes Sanford and her work in the 1950s, followed by others such as Francis MacNutt, Ruth Carter Stapleton, and John and Paula Sandford (see also Flynn & Gregg 1993; Kraft 1993; J. Lee 2019; Richardson 2005; Wardle 2001). Inner-healing prayer is a distinctively Christian type of prayer that can also be used as a spiritual intervention in explicit integration in Christian therapy. It can be especially helpful to clients who have unresolved painful memories from their past that may involve deprivation or neglect, abandonment, rejection, harsh treatment or criticism, physical or sexual abuse, and trauma. Inner-healing prayer is usually not conducted as a stand-alone spiritual intervention but rather used in the process of ongoing therapy or pastoral care and counseling (Tan 2003b). It has recently been described as part of a Christian multimodal approach to therapy called “The Life Model” (Wilder, Garzon, & Johnson 2020).

Inner-healing prayer should be used in a clinically sensitive way, always with informed consent obtained from the client. It should not be used, or used only with caution, with certain types of clients, for example, those with substance abuse problems, thought disorders, severe depression, or burnout (Garzon & Burkett 2002). In such cases, it is crucial for the therapist to engage in adequate client assessment, proper timing, and comprehensive treatment.

I have developed a seven-step model for inner-healing prayer that I first described in 1992 (see Tan 1992; see also Tan 2003b; Tan & Ortberg 2004, 64–71). This model does not have a set script for the client and does not directively instruct the client to visualize specific images of Jesus, unlike some other approaches to inner-healing prayer or healing of memories (e.g., Seamands 1985). Instead, it places the focus on prayer and the Holy Spirit’s presence and ministry during the inner-healing prayer process, emphasizing waiting upon the Lord to minister to the client in whatever way the Spirit leads. The following are the seven steps for inner-healing prayer:

1. Begin with prayer for protection from evil; ask for the power and healing ministry of the Holy Spirit to take control of the session.

2. Guide the client into a relaxed state, usually by brief relaxation strategies (e.g., slow and deep breathing, calming self-talk, pleasant imagery, prayer, and Bible imagery).

3. Guide the client to focus attention on a painful past event or traumatic experience, to feel deeply the pain, hurt, anger, and so forth.

4. Prayerfully ask the Lord, by the power of the Holy Spirit, to come to the client and minister his comfort, love, and healing grace (even gentle rebuke where necessary). It may be imagery of Jesus or other healing imagery, music (song/hymn), Scriptures, a sense of the Spirit’s presence or warmth, or other manifestation of the Spirit’s working. No specific guided imagery or visualization is provided or directively given at this point.

5. Wait quietly upon the Lord to minister to the client with his healing grace and truth. Guide and speak only if necessary and led by the Holy Spirit. In order to follow or track with the client, the counselor will periodically and gently ask, “What’s happening? What are you feeling or experiencing now?”

6. Close in prayer.

7. Debrief and discuss the inner-healing prayer experience with the client. (Tan 2003b, 20–21)

Homework inner-healing prayer can also be assigned to the client to be used during times of individual prayer at home. This seven-step model for inner-healing prayer can be modified or adapted where necessary (Tan 2007b).

Inner-Healing Prayer

The following is a hypothetical transcript of an inner-healing prayer intervention during a therapy session with a client named Jane, who is experiencing fatigue, mild depression, and a superficial, distant relationship with God:

Therapist: As we discussed in our last session, and you have read about the seven steps of inner-healing prayer, do you feel ready today to begin this prayer intervention, focusing on the painful memory you still have of your emotionally distant father?

Client: Yes, I would like to begin inner-healing prayer for this painful memory.

Therapist: Good. Before we begin, let’s remember that this is prayer and not a technique per se. We will come before the Lord with your need and painful memory and let him minister to you in whatever way he wants to and knows you need. Let’s be open and receptive to what he may want to do today, with no specific expectations or demands on our part. OK?

Client: OK.

Therapist: Good. I’ll begin with the first step. Please close your eyes and be in a receptive, prayerful mode, as I begin in prayer: “Dear Lord, we pray that you will protect us from evil, and come in the presence and power of the Holy Spirit, and minister to Jane your healing grace and truth for the painful memory she has. Thank you for your love and presence with us. In Jesus’s name we pray. Amen.” Now keep your eyes closed and continue in a prayerful mode, as I move on to the second step.

Client: OK.

Therapist: Now, Jane, I’d like you to use the relaxation techniques that you learned a couple of sessions ago, to help you relax as deeply and as comfortably as possible. . . . I’d like you now to take in a slow, deep breath, . . . hold it for a few seconds, . . . and now breathe out slowly and relax, . . . letting go of all tension; . . . just relax deeply. . . . Now, Jane, again take in a slow, deep breath, . . . hold it, . . . and relax, breathing out slowly and letting go of all tension. . . . Now go back to normal breathing, as you use the second relaxation technique of calming, relaxing self-talk, . . . saying quietly to yourself. . . . Just relax, . . . take it easy, . . . letting go of all tension, . . . so that from the top of your head all the way down to your toes . . . you are allowing yourself to relax as deeply and as comfortably as possible. . . . Good. . . . Now, Jane, use the third relaxation technique of pleasant imagery. . . . In your mind’s eye, I want you to visualize or imagine as vividly and as clearly as possible a very relaxing, calming, peaceful, enjoyable, and pleasant scene, . . . like lying on the beach on a beautiful sunny day. . . . Allow this pleasant and enjoyable scene to relax you even more deeply, . . . even more comfortably. . . . How are you feeling now, Jane?

Client: I’m feeling very relaxed and calm, feeling pretty good.

Therapist: OK, good. Now I’d like you to switch the focus of your attention to something that is not as pleasant. I would like you to go back in your imagination and see yourself as a young girl in elementary or primary school and picture your father at home, sitting in his chair and reading the newspapers and not paying much attention to you. . . . Can you relive that scene in your imagination? . . . Is it clear?

Client: Yes. I can see it happening again; . . . it’s actually quite painful (with eyes beginning to tear up a bit). . . .

Therapist: OK . . . I would like you to continue to see that scene clearly and to experience your feelings as fully as possible, and not avoid them or block them out. Do not just look at yourself in that scene but try to actually be yourself in that scene, so that you’re actually experiencing those feelings yourself afresh at this moment.

Client: I can feel the painful emotions . . . (with some more tears)

Therapist: I know this is hard for you, but it’s important for you to continue to experience these painful feelings and stay with the scene, with your father still reading the newspapers. . . .

Client: OK . . .

Therapist: Also, while keeping your eyes closed, please tell me aloud, Jane, . . . What are you experiencing now, how are you feeling, and what’s happening? . . . so I can follow you and track with you.

Client: I’m feeling lonely . . . and deeply hurt . . . that my father is still hiding behind his newspapers and not noticing me although I try to get his attention. . . . I wonder if he really loves me although he does provide material things for me and my family. . . . I feel alone and isolated and ignored, and I feel like crying (with tears). . . .

Therapist: (after some time has passed) Jane, continue with that painful scene in imagery and continue to feel the painful emotions. . . . At this point, I’d like to pause here and pray for the Lord to come and minister to you, by the power and presence of the Holy Spirit, and to touch you with his healing grace and truth, OK?

Client: OK . . .

Therapist: Dear Lord, I pray that you will now come by the power of the Holy Spirit, to walk with Jane into this painful memory, and lovingly minister your healing grace and truth to her in whatever way is needed or appropriate, according to your will. Thank you, in Jesus’s name. Amen. Now, Jane, just wait for a few moments and be in a receptive, open, prayerful mode, allowing the Lord to minister to you, to speak to you . . .

Client: OK . . .

Therapist: (after a few moments have passed) Jane, please tell me now what’s going on. . . . What are you experiencing? . . . What are you feeling?

Client: (with some tears but a smile on her face) It’s deeply touching and healing what I’m experiencing. . . . I actually sense the presence of Jesus with me, although I can’t see his face clearly. . . . He is having lunch with me, spreading out a blanket with a picnic basket, . . . and he eats a leisurely lunch with me, giving me his full and loving attention, . . . and he speaks to me and tells me that I am his beloved child and very precious to him (with some tears). . . . I feel really close to him, and my heart is experiencing some warmth and joy and . . . deep peace. . . . I feel that I can experience God more now as a loving and present heavenly Father or Parent. . . .

Therapist: Good . . . just continue to let the Lord minister . . . to you. . . . Continue to receive from him. . . .

Client: OK . . .

Therapist: (after some more moments have passed) Can you tell me now what’s happening, what you’re feeling or experiencing now?

Client: Yes . . . I continue to experience the presence of Jesus. . . . I also sense that he is gently telling me to let go of any resentment I may have toward my father, and to forgive him. . . . At least he works hard to provide for my material needs. . . . I can also see more clearly now with God’s help that this is the way my father expresses his love for me, . . . and I actually feel more gratitude and some warmth toward him now, as I let go of any resentment toward him and forgive him. . . . I also ask God to forgive me of any resentment or wrong attitudes I may have had toward my father all these years. . . . I feel more released and at peace.

Therapist: That’s beautiful, Jane. . . . Anything else before we close in prayer?

Client: No . . . I’m ready to pray.

Therapist: OK, let’s close in prayer. Would you like to start?

Client: OK . . . Dear Lord, thank you so much for this deeply touching and healing time with you, . . . for giving me such a healing image of you having lunch just with me. . . . Please continue to heal me and make me more whole so that I can know you more deeply and serve you better. Thank you in Jesus’s name. Amen.

Therapist: Dear Lord, we thank you for your healing grace and loving truth that you allowed Jane to experience today. . . . Continue your healing work in her life, and be with us and lead us as we go on with the therapy sessions here. In Jesus’s name. Amen. Jane, just before you go, do you have any comments or questions about this experience in inner-healing prayer that you’ve just had? Let’s debrief and discuss it now.

Client: It was a deeply touching and healing experience for me, thank you. Could I use these steps of inner-healing prayer on my own, in my daily quiet time with the Lord?

Therapist: Yes, that’s a good idea. I was about to ask you to do exactly this as a “homework assignment.” Are you OK with doing this?

Client: Yes, and thank you again!

Therapist: You’re welcome, Jane. Take care, and God bless! See you again next week. (adapted from Tan 2007b, 105–107)

It is important to note that inner-healing prayer does not always go so well. Some clients may have difficulty recalling their painful memories in a vivid way in imagery and may need a more narrative approach in which they simply tell their painful stories verbally and pray over them. Another option is to role-play the painful situation with such clients, ending with prayer. Clients should not be forced to keep trying to recall or relive their painful memories when they are having trouble doing so. Clients who do not experience any significant healing after an inner-healing prayer time need to be reassured that the Lord has promised grace sufficient for their need, even if they do not experience significant healing at the moment (cf. 2 Cor. 12:9–10). The importance of forgiveness also needs to be addressed. Inner-healing prayer is therefore not a panacea for all painful memories and their associated problems, but it can be a potentially helpful spiritual intervention in Christian therapy, including Christian cognitive behavior therapy (CBT). It can help facilitate deeper levels of emotional processing and cognitive restructuring and change. Inner-healing prayer emphasizes a more receptive and contemplative prayerful mode on the part of both the client and the therapist, consistent with more recent versions of CBT, which are based on mindfulness and acceptance (Tan 2007b).

Although there is some research support for the effectiveness of Christian CBT that includes the use of religious or Jesus imagery with Christian clients suffering from depression (e.g., Propst 1980; Propst et al. 1992), controlled outcome studies that specifically evaluate the effectiveness of inner-healing prayer are still lacking. Furthermore, the religious or Jesus imagery used in the Propst studies involved dealing with present and future-oriented situations, and not with painful memories from the past (Garzon & Burkett 2002). Inner-healing prayer also does not necessarily include Jesus imagery (Tan 2007b). Further research is needed to better evaluate the effectiveness specifically of inner-healing prayer.

An innovative development that combines inner-healing prayer with the repeated use of a time line of a client’s life consisting of actual memories has been described as “the healing timeline” by Catherine Thorpe in her so-titled book (2008). This new approach has three basic steps:

1. Clients present a current problem or situation to a counselor. The client and counselor ask God through prayer to lead them to a former memory that needs healing in order to bring relief to the current problem.

2. The client invites Jesus into the memory scene. The client listens and watches as Jesus intervenes and speaks into the situation.

3. After the internal interaction with Jesus, the counselor leads the client through a time line of their life, consisting of real memories. The client nods when these memories are recalled, and the time line continues without discussion until the client’s current age. Seeing Jesus in the memory scene and repetitions of the time line are alternated until no distress remains in the memory scene. (Thorpe 2008, 8–9)

This new use of the healing time line also needs further research.

Prayer for deliverance is another form of prayer that needs to be briefly mentioned (Tan 1996c). Sometimes also called exorcism, prayer for deliverance may be necessary if a client seen in Christian therapy shows signs of being demonized, or oppressed by demons or evil spirits (see Bufford 1988; MacNutt 1995; see also Appleby 2006, 2009, 2013; J. Lee 2019). This is a controversial area, and many Christian therapists may choose to refer such clients to pastors, pastoral counselors, or prayer ministry teams who may have more training and experience in dealing with such cases. Nevertheless, at times a Christian therapist may need to deal with an obviously demonized client by praying a prayer of deliverance such as “In the name of Jesus, I command you to leave this person now, and go where Jesus sends you, never to return again to afflict or oppress this person.” Informed consent from such a client should, of course, first be obtained, if possible, before prayer for deliverance or any other form of prayer is used as a spiritual intervention in explicit integration in Christian therapy.

Prayer can be potentially misused or abused in therapy, and there are dangers inherent in superficial inner-healing prayer approaches (see Alsdurf & Malony 1980; Malony 1987), including using prayer as an escape from dealing more deeply with painful issues in therapy. Christian therapists therefore differ in how explicitly they integrate spiritual interventions, such as prayer and the use of Scripture and other spiritual disciplines, into therapy sessions with clients, with some advocating caution but not censure (e.g., McMinn 1996; McMinn & McRay 1997). Yet prayer, including inner-healing prayer, can be used in a spiritually meaningful and therapeutically helpful way in therapy, especially with highly spiritual or religious clients such as orthodox Christians, who may prefer the explicit use of prayer and Scripture (Gass 1984) and open discussion of religious and spiritual issues (Rose, Westefeld, & Ansley 2001). When appropriate, explicit integration in Christian therapy should be conducted in a clinically sensitive, ethically responsible, and professionally competent way, with full informed consent from the client and appropriate caution and careful timing following the client’s lead and preferences (see Tan 1996b, 1996c). This is important because some highly religious clients may not find in-session prayer to be helpful (see, e.g., Martinez, Smith, & Barlow 2007 regarding a study of 152 Church of Jesus Christ of Latter-Day Saints clients seen at a university counseling center); therefore, such prayer should not be imposed on them (see also Magaletta & Brawer 1998). However, a survey specifically of first-visit Christian clients and their therapists found that 82 percent of such clients wanted audible prayer in counseling, but more-liberal, Catholic, and younger clients may be less interested in having prayer included in counseling sessions (Weld & Eriksen 2007). Christian therapists therefore must be cautious in how they use prayer in therapy sessions.

More broadly, Nathaniel Wade, Everett Worthington, and David Vogel (2007) found that clients with high religious commitment had greater improvement in their presenting problem after receiving religiously tailored interventions in Christian therapy compared to clients with low religious commitment. A client’s level of religious commitment is therefore important to assess before using religious interventions, such as prayer, in Christian therapy.

A recent study on prayer and subjective well-being found that of six prayer types (adoration, confession, thanksgiving, supplication, reception, and obligatory prayer), three forms of prayer (adoration, thanksgiving, and reception involving a contemplative attitude of openness, receptivity, and surrender) were positively related to measures of well-being (Whittington & Scher 2010). These three forms of prayer seem to be more God-focused and less ego-focused. In another study on the functions of prayer in the coping process, the prayer functions of seeking guidance and expressing gratitude were reported by participants to be the most effective (Bade & Cook 2008).

Kevin Ladd and Bernard Spilka (2002, 2006) categorize prayer as inward prayer (focusing on oneself), outward prayer (focusing on others), and upward prayer (focusing on the divine or higher power). Some recent research has shown that inward, outward, and upward prayer are associated with internal dialogue, but only upward prayer mediated the relationship between internal dialogue and well-being (Puchalska-Wasyl & Zarzycka 2020). In another study, those in the inward prayer and outward prayer conditions felt more resolved, at peace, and content than participants in the thought condition. They also had significantly greater cognitive understanding of a personal problem (Parks-Stamm, Pollack, & Hill 2020). A comprehensive treatment of the psychology of prayer from a scientific approach has been provided by Spilka and Ladd (2013).

Scripture

A second major example of the use of religious and spiritual resources in explicit integration in Christian therapy is the use of Scripture or the Bible (or other sacred texts in other religious approaches to therapy), especially in Christian CBT (Tan 2007b; Tan & Johnson 2005; see also Garzon 2005). The Bible is God’s inspired Word (2 Tim. 3:16) and can be used in therapy with Christian clients who want to discuss biblical truths relevant to their struggles in life, for various purposes, such as “to comfort, clarify (guide), correct (cognitively restructure), change character, cleanse, convict (convert), and cure (or heal) (e.g., see 2 Tim. 3:16; John 15:3; Ps. 119:9, 11; Heb. 4:12; 1 Pet. 2:2; Ps. 119:105; Ps. 119:97–100; 1 Pet. 1:23; Rom. 10:17; John 8:32)” (Tan 2007b, 108).

Scripture can be used in different ways in Christian therapy, including the following: indirectly by alluding to biblical truth; directly but generally by referring to examples or teachings in the Bible without citing chapter and verse; directly but specifically by referring to certain texts of Scripture, citing chapter and verse; by reading, meditating, memorizing, hearing, or studying Scripture (see Tan & Gregg 1997, 79–91); or by assigning Scripture for homework reading, study, meditation, or memorization (see Tan 2007b, 108).

Garzon (2005) has described several interventions that apply Scripture in psychotherapy, such as a Christian devotional meditation approach for anxiety (Garzon 2013), using scriptural truth meditation. The first version focuses on God’s character, such as “God is merciful,” “God is good,” and “God is in control.” The second version focuses on a Bible passage such as Psalm 23:1 (“The LORD is my shepherd”), or 1 John 4:8b (“God is love”) (see Garzon 2013, 77–78). This Christian devotional meditation approach is therefore God-centered. Mindfulness interventions have also been adapted for conservative Christians by using Christian-accomodative breath meditation and Christian-accomodative loving-kindness meditation, which are both more God-centered (Garzon & Ford 2016; see also Blanton 2019; Coe & Strobel 2019). Meditation, prayer, and contemplation as Christian practices in counseling and psychotherapy are receiving more attention in the areas of research and clinical application (see, e.g., Knabb, Johnson, & Garzon 2020; see also Knabb 2021). They include Ignatian spirituality, medieval apophatic contemplation, Puritan practices of meditation and contemplation, the Immanuel Prayer Approach and inner healing prayer in The Life Model, and the Jesus Prayer.

The use of Scripture in Christian therapy is especially relevant in Christian CBT, which focuses on cognitive restructuring of dysfunctional thinking that often includes unbiblical or sinful assumptions. In addition to standard CBT questions used in cognitive restructuring (e.g., “On what basis do you say this? Where is the evidence for your conclusion?” “Is there another way of looking at this?” “If your conclusion is true, what does it mean to you?”), Christian CBT that uses Scripture to challenge unbiblical thinking will include other questions such as these: “What do you think the Bible has to say about this?” or “What do you think God has to say about this?” (see Tan 2007b, 108). There are several helpful resources that a Christian therapist can consult about using Scripture with clients in therapy, with careful biblical interpretation (see, e.g., Kruis 2013; K. R. Miller 2014; K. R. Miller and Miller 2014, 2017; P. A. Miller 2013; see also Callaway & Whitney 2022; Clinton & Hawkins 2007; Crabb 2009; Holeman 2012; Hurding 1992; Hutchison 2005; B. Kellemen & Forrey 2014; H. Lambert 2016; McKnight 2018b; Monroe 2008; Osborne 2006; Piper 2017; Powlison 2003; Takle 2008).

Scripture can also potentially be abused or misused in Christian therapy (C. B. Johnson 1987). The thoughtless and superficial use of Scripture in therapy can lead to harmful consequences. Philip G. Monroe (2008) has emphasized the need to pay careful attention to issues relating to contextualization in the use of the Bible in therapy. He suggests several key questions that Christian therapists need to ask themselves to clarify why they may want to use Scripture in therapy with clients, such as “Why do I want to have them read this text? What do I hope to accomplish through it (e.g., to be provoked, taught, comforted, connected to something greater than self, to change one’s focal point, etc.)? What barriers might hinder this goal? How might they misinterpret my intervention?” (Monroe 2008, 56).

Use of Scripture in Therapy

The following is another hypothetical transcript showing how Scripture was used to help a client challenge and change her distorted and unbiblical way of thinking about anger.

Client: I feel badly whenever I experience even mild anger at my father for not being more expressive of affection toward me when I was a child growing up. I tend to block the anger out or deny it because I believe that it’s wrong or sinful for me as a Christian to get angry at all. . . . But the anger doesn’t really go away, and I eventually feel more fatigued and depressed.

Therapist: Let’s take a closer look at your specific thought or belief that anger is always wrong or sinful. . . . On what basis do you believe that is true? What do you think the Bible has to say about this?

Client: I remember texts in different parts of the Bible commanding us to put away anger and wrath and malice, but I can’t recall the specific references now. I feel guilty whenever I feel anger. . . .

Therapist: OK, would you like to look at the Bible more closely and see what it actually says or teaches about anger?

Client: Oh yes! I’ve been struggling with this issue for quite a while. . . .

Therapist: Can you think of any other Bible verses or passages that are relevant to our discussion?

Client: Not really . . . hmmm . . . wait a minute. I do recall Jesus throwing out the money changers in the temple, . . . so maybe there is a type of anger like when God gets angry . . . or Jesus gets angry, and it’s not sinful, it’s OK; . . . but I still feel that when I get angry, it’s not OK, because I’m not God.

Therapist: Okay, you already see that at the very least, when Jesus or God gets angry, it is not sinful or wrong, so there is a type of anger that may not be sinful. Some call this righteous indignation. Can you think of other Bible verses or passages that may teach this more directly?

Client: Come to think of it, didn’t Paul say something in the Bible like, “Be angry, but do not sin”?

Therapist: That’s a good text you recalled. It’s actually found in Ephesians 4:26. . . . Would you like to read this passage?

Client: Sure. (Reads from the Bible the therapist hands over to her.)

Therapist: What do you think Ephesians 4:26 means?

Client: Well, at least it says we can be angry but must not sin in our anger.

Therapist: It sounds like you are seeing now that anger is not always wrong or sinful. (adapted from Tan 2007b, 108–109)

This conversation demonstrates how a Christian therapist can use the Bible in a therapy session with a Christian client who wants to openly and directly discuss scriptural teaching (see also Tan 2013a; Tan & Johnson 2005). Scripture can be used in a sensitive and effective way to help in the cognitive restructuring of clients’ unbiblical or dysfunctional thinking. Even the late Albert Ellis, founder of rational emotive behavior therapy (REBT), acknowledged that the Bible as a self-help book has probably helped more people than all therapists combined, in terms of facilitating significant changes in personal functioning (A. Ellis 1993b).

Referral to Religious Groups

A third major example of the use of religious and spiritual resources in explicit integration in Christian therapy is referring the client to religious groups such as churches or parachurch groups within the client’s religious belief system. These religious groups often provide fellowship, support, and prayer that can facilitate deeper healing and growth for clients. They can also help clients make a more effective transition through the termination phase of therapy. Examples of such groups include “small groups, Bible study groups, recovery groups, prayer groups, fellowship groups, religiously oriented or Christ-centered 12-step programs, youth groups, and so forth” (Tan 1996c, 376).

Many churches and parachurch organizations also provide lay counseling services without charge, to which clients can be referred for further help and support. The lay or paraprofessional counselors are usually selected, trained, and supervised in a systematic and careful way (see Tan 1991, 2002b, 2013b, 2013c; Tan & Scalise 2016; see also Tan 2019c, 135–148). Referral to lay counselors in churches and parachurch groups can be especially helpful to clients who may not be able to afford to have or continue professional therapy because of financial difficulties.

Referral to religious groups should be done in a sensitive and supportive way, in full collaboration with the client, and for the benefit and welfare of the client.

Explicit Integration: Dealing with Spiritual Issues in Therapy

A second major component of explicit integration is dealing with spiritual issues in therapy. Clients often see counselors and psychotherapists for help with problems that have spiritual or moral aspects and even causes (see, e.g., Crabb 1987; F. J. White 1987). Explicit integration in psychotherapy will involve dealing with such spiritual and religious issues presented by the client in an open and direct way, with the client’s full informed consent. This will first require an initial and adequate spiritual assessment of the client and the problems presented. Kenneth Pargament has suggested the following key questions for use in an initial spiritual assessment of the client in an intake session:

“Do you see yourself as a religious or spiritual person? If so, in what way?” (assessing the salience of spirituality to the client); “Are you affiliated with a religious or spiritual denomination or community? If so, which one?” (assessing the salience of a religious affiliation to the client); “Has your problem affected you religiously or spiritually? If so, in what way?” (assessing the salience of spirituality to the problem); and “Has your religion or spirituality been involved in the way you have coped with your problem? If so, in what way?” (assessing the salience of spirituality to the solution). (2007, 211)

Other suggestions for conducting an initial spiritual or religious assessment of the client can be found in H. Newton Malony’s (1988) religious status interview approach and M. Scott Peck’s (1993) questions for taking a spiritual history. Peck actually advocated that all psychiatry residents should be taught how to obtain a spiritual history of their clients in their first month of training, alongside learning how to take a more general history and conducting a mental status exam.

Spiritual and religious issues can alsoemerge during the course of therapy with clients. They include broad existential struggles such as searching for meaning in life, dealing with the fear of death and mortality, and choosing authentic values in life (see, e.g., Wong et al. 2007). The issues can also be more specific spiritual and religious issues such as doubts; sins; struggles with guilt, bitterness, and unforgiveness; “dark nights of the soul”; and other spiritual struggles (see, e.g., Pargament 2007; Pargament & Exline 2022), and even possible demonization. Negative aspects of spiritual and religious experiences, such as so-called toxic faith (Arterburn & Felton 1991) or religious addiction (Booth 1991), are other spiritual issues that may need to be explicitly explored and dealt with in therapy.

Neil Anderson has emphasized the essential need for Christian clients to understand and appropriate their identity in Christ from a biblical perspective, in order to live a victorious Christian life, in the following three main areas: “I am accepted in Christ” (John 1:12; 15:15; Rom. 5:1; 1 Cor. 6:17, 19–20; 12:27; Eph. 1:1, 5; 2:18; Col. 1:14; 2:10); “I am secure in Christ” (Rom. 8:1–2, 28, 33–34, 35; 2 Cor. 1:21; Phil. 1:6; 3:20; Col. 3:3; 2 Tim. 1:7; Heb. 4:16; 1 John 5:18); “I am significant in Christ” (Matt. 5:13–14; John 15:16; Acts 1:8; 1 Cor. 3:16; 2 Cor. 5:17–20; 6:1; Eph. 2:6, 10; 3:12; Phil. 4:13) (2003, 75–76). He has also described seven steps to freedom in Christ, in which a negative element in the fallen world is replaced with a biblical answer:

Counterfeit versus real

Deception versus truth

Bitterness versus forgiveness

Rebellion versus submission

Pride versus humility

Bondage versus freedom

Acquiescence versus renunciation (see N. T. Anderson, Zuehlke, & Zuehlke 2000, 152–163, 384–411)

Gary Collins has listed and described several important spiritual issues often encountered in Christian therapy, including “sinful thoughts and actions; legalism; self-sufficiency; pride; bitterness; non-Christian values; lack of: understanding of spiritual issues, spiritual nourishment, giving, balance, commitment, simplicity, Holy Spirit power, spiritual disciplines, and involvement with the church; suffering; and spiritual warfare” (2007, 825).

It is crucial for the Christian therapist to handle spiritual and religious issues in an empathic way, with gentleness and respect for the client. The therapist should not impose their own religious convictions on the client.

Timing is also important in helping clients deal with their spiritual and religious issues, especially if they involve conflict and spiritual struggles. If such issues are confronted too soon or insensitively, the client’s faith may be impacted in a negative way (F. J. White 1987). The Christian therapist will therefore be sensitive to the client’s readiness for discussing these issues in an open and direct way and follow the client’s pace. The client’s freedom to choose and ultimate responsibility in making decisions must always be respected. For more-severely disturbed clients, the therapist will wisely refrain from confronting and challenging their religious convictions, even if they are clearly dysfunctional, until such clients have emotionally stabilized and are better able and ready to deal with their dysfunctional religious beliefs (see Tan 1996c).

Christian therapists must also learn how to help clients from diverse religious and cultural backgrounds deal with more general religious and spiritual issues by having some understanding of other religions (see, e.g., Richards & Bergin 2014; also Dowd & Nielsen 2006; Hood, Hill, & Spilka 2018; Lovinger 1984, 1990; Paloutzian & Park 2013; Pargament, Exline, & Jones 2013). Robert Lovinger (1984) has provided some helpful examples of countertransference on the part of the therapist when dealing with religious issues in therapy with clients who are religiously committed. Therapists must be careful not to fall into these therapeutic mistakes that come from their own countertransference or unconscious negative reactions toward clients; examples of such mistakes include arguing with clients about doctrinal issues, having long discussions about philosophical and theological topics with no therapeutic purpose, and not adequately exploring the reasons for a client having made a significant change in religious orientation, especially in the direction of the therapist’s own religion or denomination (Lovinger 1984).

Sidebar 18.2: Spiritual Disciplines and Practices

(see Eck 2002, 273)

Brian Eck has comprehensively listed thirty-nine spiritual disciplines and practices that include both traditional spiritual disciplines and authentic disciplines and has explored their therapeutic use in clinical practice. He divides them into three major categories:

Cognitive: meditation, listening, Scripture, study, prayer, discernment

Behavioral: simplicity, frugality, fasting, chastity, body care, saying no/yes, slowing, Sabbath, solitude, silence, secrecy, service, servanthood, sacrifice, suffering, dying well

Interpersonal: confession, repentance, forgiveness, submission, humility, worship, Eucharist, singing, celebration, fellowship, community, hospitality, healing, witnessing, testimony, intercession, guidance

He emphasizes that the use of spiritual disciplines and practices in therapy should be done with “a grace filled, God empowered focus as a means of grace and mercy, and not as a legalistic or coercive process” (272). They should therefore be used in ethical and appropriate ways for the spiritual formation and therapeutic benefit of the client and with the client’s full informed consent (see Chapelle 2000; Tan 2003c).

Explicit Integration: Fostering Intrapersonal Integration and the Development of Spirituality in the Therapist and the Client Intrapersonal integration or personal integration (i.e., one’s own appropriation of faith and integration of psychological and spiritual experience) and the spiritual development of the therapist and the client are also crucial aspects of explicit integration in Christian therapy (Tan 1996c). Explicit integration will often include discussion and application of spiritual disciplines as a means of God’s grace for helping both the therapist and the client to grow in deeper Christlikeness (Rom. 8:29) and spiritual maturity (see Tan 1996b, 1998). Several helpful books are available that clearly describe spiritual disciplines for spiritual growth and transformation (see, e.g., Foster 1988, 2018; Ortberg 2002; Tan & Gregg 1997; Whitney 2014; Willard 1988; see also Bennett 2017; A. A. Calhoun 2015; Comer 2019; Ortberg 2014; Phillips 2015; Shigematsu 2018; Swoboda 2018; Warren 2016). Disciplines of the Holy Spirit (Tan & Gregg 1997) identifies the following spiritual disciplines as disciplines of the Holy Spirit: disciplines of solitude in drawing near to God (e.g., solitude and silence, listening and guidance, prayer and intercession, study and meditation), disciplines of surrender in yielding to God (e.g., repentance and confession, yielding and submission, fasting, and worship), and disciplines of service in reaching out to others (e.g., fellowship, simplicity, service, and witness). Adele Calhoun has listed and described at least seventy-five spiritual disciplines as practices that can transform us under seven major categories: (1) worship, (2) open myself to God, (3) relinquish the false self, (4) share my life with others, (5) hear God’s Word, (6) incarnate the love of Christ, and (7) pray (2015, 7–8). Kyle Bennett (2017) has recently emphasized and described spiritual disciplines as practices of love for the sake of others and the life of the world, and not as individualistic practices to feel good or only for one’s individual and personal spiritual growth.

Spiritual disciplines can, however, be potentially dangerous (cf. Plummer 2009). If they are practiced in a way that is legalistic, dogmatic, and self-absorbed, they can lead to pride, self-sufficiency, and self-righteousness, thus ultimately harming one’s spiritual life and development. A Christian therapist will therefore also emphasize what Gary Thomas (2002) has called the authentic disciplines or circumstantial spiritual disciplines (Tang 2008) that are not within our voluntary control, as vital additions to the traditional spiritual disciplines. These so-called authentic disciplines include selflessness, waiting, suffering, persecution, social mercy, forgiveness, mourning, contentment, sacrifice, and hope and fear (G. Thomas 2002). They focus more on God seeking the face of men and women and emphasize a God-ordained spirituality, under his sovereignty and not our own control. Their ultimate goal is to learn “to love with God’s love and . . . serve with God’s power” (G. Thomas 2002, 16). Such authentic disciplines, including suffering and painful experiences that lead to ultimate spiritual formation and growth into deeper Christlikeness, have recently been cited in the more general psychological literature as highly stressful life events and trauma that lead to perceived growth, labeled “posttraumatic growth,” “stress-related growth,” and “benefit-finding” (see, e.g., Helgeson, Reynolds, & Tomich 2006; Park & Helgeson 2006; see also L. G. Calhoun & Tedeschi 2006, 2013; Park 2010; Park et al. 2017). Biblical meaning-making and benefit-finding can be part of dealing with experiences of authentic disciplines that clients may have in their lives. However, a biblical perspective on suffering and Christian spiritual formation into deeper Christlikeness will go beyond posttraumatic growth and benefit-finding that can be too focused on self-improvement and present benefits and blessings to oneself rather than on eternal results that may not be experienced on earth (see Tan 2019a). Furthermore, suffering is not the only or necessary way for growth. Recent research has shown that positive and joyful experiences can also lead to growth, called postecstatic growth, and not just posttraumatic growth as a result of suffering (Tan 2019b; see also Mangelsdorf, Eid, & Luhmann 2019), and this more-balanced view is consistent with Scripture (see Tan 2019b).

The traditional spiritual disciplines should be used in a grace-filled, nonlegalistic way in the Christian therapist’s life to facilitate the therapist’s own spiritual growth so that the therapist can more effectively help the client to also grow spiritually. The ultimate goal of Christian therapy is not only to alleviate symptoms but also to deepen spiritual maturity in the client. Appropriate spiritual self-disclosure by the Christian therapist (see Denney, Aten, & Gingrich 2008) is an important part of sharing traditional spiritual disciplines and how they can be used in sessions as well as in between sessions as homework assignments. It is also a significant part of engaging in biblical meaning-making and benefit-finding as the therapist and the client explore and discuss experiences of authentic disciplines, including suffering and painful events in their lives, as well as more positive and joyful experiences that can lead to deeper spiritual formation and growth in Christ. Some degree of spiritual direction—the process of discerning and surrendering to God’s will and deepening one’s personal relationship with God, in the context of one’s life experiences, by meeting with someone for prayer and spiritual conversation (see Benner 2002, 94)—is therefore an appropriate part of explicit integration in Christian therapy (see Tan 2003c; see also R. Kellemen 2005a, 2005b). Ultimately, however, it is the Holy Spirit who transforms us into deeper Christlikeness (2 Cor. 3:18), and not the spiritual disciplines or practices themselves (see Tan 2019c; Tan & Gregg 1997).

Some leaders in the Christian therapy field do not advocate integrating spiritual direction into Christian therapy (e.g., McMinn & Campbell 2007). However, many others support integrating spiritual direction, including the use of spiritual disciplines, into Christian therapy (see Tan 2003c; see also Benner 2005b; Crabb 2003; G. W. Moon & Benner 2004). Although Benner (1988) earlier felt that Christian therapy and spiritual direction cannot be integrated because they are so different in their focus and role demands, he later changed his view and is supportive of a Christian psychospiritual therapy that includes spiritual direction (Benner 1998). In fact, he has developed an approach called the intensive soul care retreat (see Benner 2005b). He also cites Bernard Tyrell’s Christotherapy as another example of combining spiritual direction and psychotherapy (see Tyrell 1982). In fact, psychotherapy itself can be viewed as “work in the Spirit” (Kunst & Tan 1996), even conceptualized as a spiritual discipline, because it is an intentional practice that involves facing our brokenness and being dependent on God’s grace, eventually helping us in the sanctification process for the ultimate purpose of being formed in the image of Christ (K. M. White 2020).

Gary Moon and his colleagues (1993) found that out of a list of twenty spiritual guidance techniques, those most frequently used by Christian psychotherapists, pastoral counselors, and spiritual directors were spiritual history, discernment, forgiveness, solitude or silence, intercessory prayer, and teaching from Scripture. These findings are consistent with previous research conducted in this area. Moon and his colleagues also reported that doctoral-level religious mental health clinicians were less likely than master’s-level practitioners to use such explicit spiritual guidance techniques. In a more recent general study of ninety-six psychologists and their reported use of twenty-nine recommended religious/spiritual psychotherapy behaviors, Royce Frazier and Nancy Hansen (2009) found that in general, and for 90 percent of the twenty-nine behaviors, the psychologists practiced them less frequently than their importance ratings indicated they should be used. Also, the greater the psychologists’ religious/spiritual self-identification, the higher the likelihood of them reporting engaging in these behaviors in psychotherapy.

A study with one hundred therapists sampled mainly from alumni of an APA-accredited Christian doctoral program in clinical psychology (D. Walker, Gorsuch, & Tan 2005) found that coursework in integration and theology was not significantly related to the explicit use of religious and spiritual interventions in therapy. Instead, it reported that clinical training with religious clients (i.e., number of contact hours with religious clients) and intervention-specific training with religious and spiritual interventions (i.e., number of clinical supervision hours devoted to religious and spiritual interventions in therapy) were significantly correlated with more-frequent use of religious and spiritual interventions in therapy and also self-reported competency. A later study of 162 student therapists from three APA-accredited Christian doctoral programs in clinical psychology (D. Walker, Gorsuch, et al. 2008) similarly found intervention-specific training to be potentially the most efficient way for training therapists to explicitly use religious and spiritual interventions in clinical practice. The role of Christian clinical supervision is therefore crucial in developing therapist integration skills, including the explicit use of Christian spiritual interventions and spiritual disciplines in therapy (Tan 2009a; see also Barto 2018; Tan 2007c; T. S. Watson 2018).

Some cautions, mentioned earlier in this chapter, are needed in the practice of explicit integration in Christian therapy, which includes the use of spiritual interventions such as prayer, Scripture, and the spiritual disciplines (see, e.g., Martinez, Smith, & Barlow 2007; Magaletta & Brawer 1998; Weld & Eriksen 2007). Further research on the effectiveness of such explicitly Christian spiritual interventions in therapy is also needed, although outcome research to date has yielded empirical support for both the efficacy (Worthington et al. 2011) and the effectiveness of Christian therapy in actual clinical settings (Wade, Worthington, & Vogel 2007; see also Pargament 2007; T. B. Smith, Bartz, & Richards 2007). An earlier meta-analytic review of thirty-one outcome studies (eighteen with true experimental designs and six with quasi-experimental designs) of religiously or spiritually oriented therapies with a total of 1,845 clients yielded an average effect size of 0.56 (T. B. Smith, Bartz, & Richards 2007). Some empirical support was therefore found for the effectiveness of such therapies, especially in treating clients suffering from depression, anxiety, stress, and eating disorders. The majority of the clients were Christian (73 percent) and Muslim (24 percent) in their religious affiliation, with most of the outcome studies involving Christian or Muslim therapy (see Abu Raiya & Pargament 2010; Tan & Johnson 2005; see also Keshavarzi et al. 2021). A larger meta-analytic review of fifty-one samples (including twenty-four CBT samples) from forty-six separate outcome studies of religious and spiritual therapies with a total of 3,290 clients came to similar conclusions, further supporting the efficacy or effectiveness of such therapies (Worthington et al. 2011). A recent and even larger meta-analysis of ninety-seven outcome studies (n = 7,181) on religious and spiritual therapies, including Christian therapies, showed religious and spiritual therapies had significantly greater improvement in the psychological and spiritual functioning of clients compared to no-treatment and nonreligious/spiritual therapies. In more rigorous additive studies, religious and spiritual studies were found to be as effective as standard approaches in decreasing psychological distress but led to significantly greater spiritual well-being (Captari et al. 2018). The empirical evidence supporting the effectiveness of religious and spiritual therapies, including Christian therapies, is therefore solid and substantial (see also Hook et al. 2019).

An earlier review of empirically supported treatments (ESTs) for Christian counseling concluded that Christian ESTs include Christian cognitive therapy for depression and three marriage enrichment interventions (PREP, Interpersonal Communication Program, and Hope-Focused Couple Approach). A few other Christian therapies have received some support for their efficacy but are not ESTs yet, including Christian CBT for eating disorders, Christian lay counseling in general, Christian group treatment for unforgiveness, and Christian devotional meditation for anxiety (Worthington et al. 2008; see also Worthington et al. 2013). A recent review of empirically supported religious and spiritual therapies in general concluded that Christian accommodative cognitive therapy for depression and twelve-step facilitation for alcoholism were efficacious, and Muslim psychotherapy for depression as well as for anxiety was efficacious when used with medication. The following were deemed possibly efficacious treatments: Christian devotional meditation for anxiety, Taoist cognitive therapy for anxiety, Christian accommodative group treatment for unforgiveness, spiritual group treatment for unforgiveness, Christian accommodative group cognitive-behavioral therapy for marital discord, and Christian lay counseling for general psychological problems. Spiritual group therapy for eating disorders, when combined with existing inpatient treatment and Buddhist accommodative cognitive therapy for anger in a prison setting, were also deemed possibly efficacious (Hook et al. 2010).

Explicit integration in Christian therapy that includes the appropriate and ethical use of spiritual interventions and resources in therapy and incorporates the process of spiritual direction to a certain degree can have great potential “for deep blessing and greater wholeness and shalom for the client who freely chooses such a psychospiritual therapy that aims toward both psychological and spiritual growth as well as the reduction of psychological distress” (Tan 2003c, 20). It should be conducted in an ethically responsible, clinically sensitive, and professionally competent way, for the benefit and well-being of the client (Tan 1996c). It has received strong empirical support for its effectiveness in Christian therapies as part of religious and spiritual therapies (Captari et al. 2018; Hook et al. 2019).

This chapter on Christian faith in clinical practice has focused mainly on individual therapy, but it can also be applied to couple and family therapy (see, e.g., Ripley & Worthington 2014; Worthington 2005b; Yarhouse & Sells 2017), and to group therapy and care groups (see, e.g., Greggo 2008).

Recommended Readings

Anderson, N. T., Zuehlke, T. E., and Zuehlke, J. S. (2000). Christ-centered therapy: The practical integration of theology and psychology. Grand Rapids: Zondervan.

Appleby, D. W., & Ohlschlager, G. (Eds.). (2013). Transformative encounters: The intervention of God in Christian counseling and pastoral care. Downers Grove, IL: IVP Academic.

Benner, D. G. (1998). Care of souls: Revisioning Christian nurture and counsel. Grand Rapids: Baker.

Bufford, R. K. (1988). Counseling and the demonic. Dallas: Word.

Collins, G. R. (2007). Christian counseling: A comprehensive guide (3rd ed.). Nashville: Nelson.

Crabb, L. J. (1977). Effective biblical counseling. Grand Rapids: Zondervan.

Knabb, J. J., Johnson, E. L., Bates, M. T., & Sisemore, T. A. (2019). Christian psychotherapy in context: Theoretical and empirical explorations in faith-based mental health. New York: Routledge.

McMinn, M. R., & Campbell, C. D. (2007). Integrative psychotherapy: Toward a comprehensive Christian approach. Downers Grove, IL: IVP Academic.

Moon, G. W., & Benner, D. G. (Eds.). (2004). Spiritual direction and the care of souls. Downers Grove, IL: InterVarsity.

Pargament, K. I. (2007). Spiritually integrated psychotherapy: Understanding and addressing the sacred. New York: Guilford.

Pargament, K. I., Exline, J. J., & Jones, J. W. (Eds.). (2013a). APA handbook of psychology, religion and spirituality: Vol. 1. Context, theory, and research. Washington, DC: American Psychological Association.

Pargament, K. I., Mahoney, A., & Shafranske, E. P. (Eds.). (2013b). APA handbook of psychology, religion, and spirituality: Vol. 2. An applied psychology of religion and spirituality. Washngton, DC: American Psychological Association.

Thomas, J. C. (Ed.). (2018). Counseling techniques: A comprehensive resource for Christian counselors. Grand Rapids: Zondervan.

Worthington, E. L., Jr., Johnson, E. L., Hook, J. N., & Aten, J. D. (Eds.). (2013). Evidence-based practices for Christian counseling and psychotherapy. Downers Grove, IL: IVP Academic.

Chapters 19

The Holy Spirit and Christian Spirituality in Counseling and Psychotherapy

Christian counseling or psychotherapy can be simply described as counseling conducted by a Christian who is Christ centered, biblically based, and Spirit filled (see Tan 1999b). The role of the Holy Spirit, the Third Person of the Triune God (Father, Son, and Holy Spirit), is crucial, central, and comprehensive in Christian counseling (Tan1999b), as in Christian spiritual formation (see Chandler 2016; Tan 2019c, 2019d). Numerous works are available on the Holy Spirit from a theological perspective (see Allison & Kostenberger 2020; T. J. Burke & Warrington 2014; G. A. Cole 2007; O. D. Crisp & Sanders 2020; Fee 1994; Habets 2019; Horton 2017; Kärkkäinen 2018; Levison 2009, 2013, 2020a, 2020b; Moltmann 1997; Pinnock 1996; Thiselton 2013; Yong 2012; see also Packer 2005). There is also a growing literature on the ministry of the Holy Spirit in the context of Christian therapy and personality functioning, both articles in journals (see Coe 1999; Dodds 1999; Ingram 1996; Kunst & Tan 1996; Parker 2008; also Decker 2002; Hathaway 2018; Tan 1999a) and books (see Coe & Hall 2010b; M. G. Gilbert & Brock 1985, 1988; Pugh 2008; Sutton 2021; Vining 1995a, 1995b; Vining & Decker 1996).

The crucial role of the Holy Spirit in Christian therapy is supported by Scripture that describes the Holy Spirit as the Counselor, Comforter, Helper, and Advocate (John 14:16–17). In every counseling or therapy situation, at least three persons are involved: the counselor, the client or counselee, and the Holy Spirit, who is the Counselor par excellence (see Adams 1973). The Holy Spirit is also described as the giver of life by the Nicene Creed, supported by Scriptures in both the Old Testament and the New Testament (see Parker 2008, 286; see also G. A. Cole 2007; Levison 2009, 2013, 2020a, 2020b). The Spirit’s key role in Christian therapy as the Counselor, as well as the giver of life, means that Christian therapists must acknowledge and depend on the Spirit’s presence and healing power in every counseling situation, with a basic biblical understanding of the work and ministry of the Holy Spirit (Tan 1999b).

The Work and Ministry of the Holy Spirit

The work and ministry of the Holy Spirit can be described and biblically understood in at least three major ways: the Spirit’s power (and gifts), the Spirit’s truth, and the Spirit’s fruit (see Tan 1999b, 568).

The Spirit’s Power and Gifts

The power of the Holy Spirit is essential in Christian life and ministry (see Tan 2019d), including witnessing and evangelism (Acts 1:8), and we need to be sensitive and open to the Spirit (see McKnight 2018a; Storms 2017). Christians are commanded in Scripture to be continually filled with the Holy Spirit (Eph. 5:18), on a daily basis and moment by moment. This means that we confess our sins and yield to Jesus Christ as Lord of our lives and ask for the Holy Spirit to fill us and take control of us, so that we can be empowered by him to become more like Jesus and to do the works of Jesus (see Hayford 2005), including counseling and helping others.

Here is a brief prayer that may be helpful for those of us who want to ask for the filling of the Holy Spirit and be empowered by the Spirit to become more like Jesus in our character and ministries, including counseling and psychotherapy: “Dear Father, I come to you and ask in the Name of Jesus for you to cleanse me and fill me with the Holy Spirit and his power and presence, so that I can become more like Jesus in my life and ministries including counseling and psychotherapy. Thank you so much. In Jesus’s Name, Amen!” (see Tan 2019c, 18).

As we prayerfully yield to the Spirit’s control, he empowers us and guides us in our Christian lives and ministries (see Tan 2019c, 14–23). He also sovereignly and supernaturally gives us spiritual gifts according to God’s will, to enable us to be fruitful and faithful in the areas of ministry to which he has called us, including counseling (see Rom. 12; 1 Cor. 12; Eph. 4; 1 Pet. 4). These spiritual gifts are God’s droplets of grace, which he freely gives us to empower us to have an effective ministry with love, gratitude, and humility, which glorifies him and blesses others for eternity. They include the following spiritual gifts that are especially relevant for an effective counseling ministry led by the Holy Spirit: exhortation or encouragement (Rom. 12:8), healing (1 Cor. 12:9, 28), wisdom (1 Cor. 12:8), knowledge (1 Cor. 12:8), discerning of spirits (1 Cor. 12:10), and mercy (Rom. 12:8) (see Tan 1999b, 568). Other spiritual gifts that are often viewed as important for counseling ministries, especially from a more charismatic or Pentecostal perspective, include prophecy, teaching, faith, miracles, tongues, and intercession. Helpful definitions of twenty-eight spiritual gifts and a spiritual gifts questionnaire to help Christians discern and discover their spiritual gifts can be found in Your Spiritual Gifts Can Help Your Church Grow (C. P. Wagner 2005). William Hathaway (2018) recently reviewed some spiritual gift inventories and their validity and functions; he emphasized their lack of validity and other psychometric properties. Spiritual gift inventories should therefore be used cautiously and not be misinterpreted or overinterpreted.

Spiritual gifts have also been described as different ministries that the Holy Spirit calls us to serve in, to build up the body of Christ or the church, rather than as special abilities (the conventional or traditional view) given to us by the Spirit (see, e.g., Aker 2002; Berding 2006).

The Spirit’s Truth

The Holy Spirit is the Spirit of truth, who will teach us and guide us into all truth (John 14:26; 16:13), including psychotheological truth. Ultimately, such eternal truth will set us free (John 8:32), centered in Jesus Christ, who is the Truth (John 14:6) as well as the Way and the Life. The Holy Spirit inspired the writing of Scripture as God’s Word. The Spirit’s work and ministry, including in the counseling context, will never contradict the truth of Scripture when it is properly interpreted. The Holy Spirit will therefore always uphold the eternal validity of Scripture. The Spirit’s ministry in counseling will be consistent with the moral and ethical aspects of biblical teaching and truth.

The Spirit’s Fruit

The Holy Spirit produces the fruit of the Spirit, which is characteristic of mature Christlikeness (Rom. 8:29), fruit that is mentioned in Galatians 5:22–23: love, joy, peace, forbearance, kindness, goodness, faithfulness, gentleness, and self-control. This fruit refers basically to the fruit of agape, Christlike love, produced by the Spirit in Christian lives that are yielded to his control and empowering. The Spirit’s fruit of agape is powerfully therapeutic in counseling situations.

All three aspects of the Holy Spirit’s ministry are essential and crucial in the Christian life as well as in Christian therapy. They need to be present in biblical balance. Power without love often results in abuse. Power without truth can become heresy. However, power based on biblical truth and used with Christlike love can produce renewal and revival as well as the deep and substantial healing of broken lives.

The Work of the Holy Spirit in Counseling

The Holy Spirit can work in various ways during a counseling session itself. In more-implicit integration approaches to Christian therapy, such as in psychodynamic or psychoanalytic therapy, the Holy Spirit’s work as giver of life may be more emphasized. Stephen Parker (2008), for example, has described the Holy Spirit’s creative work in therapy by using Donald Winnicott’s object-relations theory and the concepts of transitional phenomena and object usage (see Winnicott 1966, 1971). Parker focuses especially on how the Spirit can help clients by “conferring a sense of identity and providing an environment for emergence of a strong spiritual self. The work of the Holy Spirit was also seen as tapping into the creative potential of what Winnicott (1971) calls ‘transitional phenomena,’ and in engendering new life by making God real in ways that transcend our imaginings” (Parker 2008, 292). Parker also emphasizes that the life-giving work of the Holy Spirit enables a client to still have a basic sense of hope even when all the client’s “wishes, dreams, disappointments, fears, and frustrations have been spent” (2008, 292), making God real to the client despite that person’s experiencing the absence of God.

Similarly, the Holy Spirit can work in implicit integration that is intentional and incarnational, such as in relational psychodynamic therapy or relational psychoanalysis (see, e.g., Bland & Strawn 2014a; 2014b; M. T. Hoffman 2011). The Spirit’s work is quietly but intentionally embraced and expressed by the Christian therapist in avowing that the client is worthy of love and accepting the client’s worst experiences (see Terrell 2007, 162). Steven Rogers (2007) has also described how a focus on the process and the here and now during a therapy session in object relations therapy can be understood as a powerful spiritual intervention, quietly guided and empowered by the Holy Spirit. Transcendent moments and creative experiences in Christian therapy may therefore reflect the deep but quiet work of the Holy Spirit in counseling. Psychotherapy itself can be theologically viewed as “work in the Spirit” (Kunst & Tan 1996) in bringing wholeness to broken lives. John Pugh has emphasized that the Holy Spirit works in and through the day-to-day “awful experiences of human existence” (2008, 280).

The Holy Spirit can also work in explicit integration in Christian therapy, which deals with religious and spiritual issues more directly and uses spiritual resources and religious interventions more overtly and systematically with clients. There are at least five ways in which the Holy Spirit can work during a Christian therapy session as the therapist uses a more explicit integration approach (Tan 1999b).

First, the Holy Spirit can directly help the Christian therapist quickly and accurately discern the root problems of the client by providing the Christian therapist with specific and relevant words of knowledge or wisdom (1 Cor. 12:8). From a more conservative evangelical perspective, C. R. Swindoll (1994) has referred to such experiences of receiving words of knowledge or wisdom from the Spirit (see Deere 1993, 1996) as “inner promptings,” nudges of the Spirit within the Christian counselor who is prayerfully attentive to the Spirit’s leading. Such promptings can also help the Christian therapist to engage in deeper spiritual conversation with the client, in “soultalk” (Crabb 2003). The Christian therapist can be more mindfully and attentively dependent on the Holy Spirit during a counseling session by periodically offering “flash prayers” in their heart such as these: “Spirit of God, please guide me.” “Holy Spirit, touch the client with your healing grace.” “Holy Spirit, help us at this point of impasse.” “Spirit of God, protect us and empower us.” “Holy Spirit, please comfort and strengthen the client.” The same can also happen in more implicit integration approaches such as relational psychodynamic therapy. The Holy Spirit will help us to pray in the Spirit (Eph. 6:18; Jude 20), often with wordless groans or groanings within us (Rom. 8:26).

Second, the Holy Spirit can provide spiritual direction regarding God’s will to both the Christian therapist and the client as they participate in more-explicit integration practices during a therapy session, such as praying together, discussing Scripture, and openly exploring spiritual issues. As noted earlier, the Holy Spirit can also guide in more-implicit integration approaches to Christian therapy during a therapy session.

Third, the Holy Spirit can directly touch a client in a powerful way with healing grace and power. This experience can occur anytime spontaneously and supernaturally in God’s sovereignty and by divine grace and goodness, often leading to significant or “quantum change,” as when sudden insights and epiphanies bring transformation of ordinary lives (see W. R. Miller & C’de Baca 2001). However, explicit use of prayer, and especially inner-healing prayer or healing of memories (see Tan 2003b; Tan & Ortberg 2004; see also Garzon & Burkett 2002), can be especially helpful in facilitating the occurrence of such transcendent moments that can also take place in implicit integration in therapy.

Fourth, the Holy Spirit can enable the Christian therapist to discern the presence of the demonic if there is demonization or demonic oppression in the client’s life. The spiritual gift of discerning of spirits or distinguishing between spirits (1 Cor. 12:10) can be especially helpful to the Christian therapist, especially in making an accurate differential diagnosis between demonization and mental disorder. At times, both demonization and mental illness may afflict a certain client. The Holy Spirit can also empower the Christian therapist to engage in effective prayers for deliverance and protection from the demonic, if this is called for, with proper informed consent and full collaboration from the client. At times it may be more appropriate to refer the client with possible demonization to a pastor or prayer ministry team experienced in deliverance work, preferably in the client’s own church or denomination.

Fifth, and finally, the Holy Spirit can work deeply in spiritual transformation of both the client and the therapist into greater Christlikeness as they practice the spiritual disciplines (e.g., solitude and silence, listening and guidance, prayer and intercession, study and meditation, repentance and confession, yielding and submission, fasting, worship, fellowship, simplicity, service, and witness) in the power of the Spirit (Tan & Gregg 1997), as well as discuss or reflect on growing and meaning-making through experiencing authentic disciplines usually not within our control, such as suffering, sacrifice, persecution, mourning, waiting, contentment, and hope and fear (G. Thomas 2002; see also Tan 2006b). Some of these spiritual disciplines can be practiced or discussed in the therapy session and others presented as homework assignments for the client between sessions. They can help both the therapist and the client to access more of the presence and power of the Spirit for the client’s growth and healing. It is therefore not totally true that a therapist can lead a client only as far as the therapist has gone spiritually or psychologically. The Spirit can bring both of them beyond their present level. This is the sovereign work of God and his grace alone. The Holy Spirit can therefore bring about deep and genuine growth and healing, psychologically and spiritually, in the client, and as a side effect in the therapist too, in what Reissman (1965) has called the “helper therapy” principle.

The Holy Spirit, in sovereignty as God, can work in spontaneous and supernatural ways to anoint and transform us with the Spirit’s power anyway, anytime, and anywhere he wants to, even without us doing anything, including practicing the traditional spiritual disciplines. The Holy Spirit has worked with and in all kinds of people, in all types of circumstances and situations, including all of creation throughout history (see Levison 2009, 2013, 2020a, 2020b; Thiselton 2013).

The work of the Holy Spirit in Christian therapy is therefore central and crucial as well as comprehensive and deep. Although training and competence in therapy skills are needed, Christian therapists will use such skills in dependence on the Holy Spirit as the Counselor par excellence. Scot McKnight (2018a) has described the Holy Spirit as God in us, God with us, and God transforming us, the One who transforms and transcends our human abilities.

The Holy Spirit and Christian Spirituality in Counseling

A distinctive goal of Christian therapy is to help the client to grow spiritually into deeper Christlikeness (Rom. 8:29), that is, to develop the client’s Christian spirituality (in addition to reducing the presented psychological distress). The Holy Spirit’s work is also essential in developing Christian spirituality, which needs further definition and description (see, e.g., Chandler 2016; Fee 2010; Gaultiere & Gaultiere 2021; Greenman & Kalantzis 2010; see also Barbeau & Jones 2015; Tan 2019c, 2019d).

Christian Spirituality: Definition and Description

In recent years, much has been written about spirituality in general, and Christian spirituality in particular (see Augsburger 2006; Benner 2002, 2010, 2011, 2012, 2014, 2016; Bloesch 2007; Boa 2020; Chan 1998, 2006; Foster 1998; Foster & Beebe 2009; Howard 2008; McKnight 2004; E. H. Peterson 2005, 2006, 2007, 2008, 2010, 2011, 2017; Scorgie et al. 2011; Webber 2006; Willard 1998, 2002; Willard & Black 2014; see also Chandler 2014; T. M. Crisp, Porter, & Ten Elshof 2019; Hiestand & Wilson 2019; Howard 2018; G. T. Smith 2014). There are also two journals devoted to Christian spirituality: Conversations: A Forum for Authentic Transformation (which has ceased publication) and Journal of Spiritual Formation & Soul Care.

Spirituality in a more generic and psychological sense has different meanings (Zinnbauer & Pargament 2005). However, it has been defined as a search for the sacred, for that which transcends the self (P. C. Hill et al. 2000). Steven Sandage and F. LeRon Shults (2007) have emphasized relational spirituality and defined it as “ways of relating to the sacred” (Shults & Sandage 2006, 161). Also, a recent movement in the mental health and general health-care arenas has focused on the significant relationship, often positive (but not always), between religion/spirituality and health or mental health (e.g., Koenig, King, & Carson 2012; Plante & Sherman 2001; Rosmarin & Koenig 2020; see also P. C. Hill & Pargament 2003; W. R. Miller & Thoresen 2003; Powell, Shahabi, & Thoresen 2003; Seeman, Dubin, & Seeman 2003), but there are critics of this movement (e.g., Sloan & Bagiella 2002).

Christian spirituality can also be defined and described in various ways. Alister McGrath has defined the essential meaning of Christian spirituality as consisting of “the shaping, empowering, and maturing of the ‘spiritual person’ (1 Cor. 2:14–15)—that is, the person who is alive to and responsive to God in the world, . . . and evangelical spirituality will thus be Bible-centered, . . . concerned more with the facilitation and enhancement of the personal redemptive encounter of the believer with Christ” (1995, 125). He especially emphasizes the lordship of the Holy Spirit and the importance of Christian community for the spiritual growth of Christians (see Tan 2008a, 28). McGrath also suggests that evangelical Christian spirituality will have the following four major characteristics: “be Scripture-centered; place considerable emphasis on the transforming character of the knowledge of God; rest on a solid and reliable foundation in the self-revelation of God; and rediscover the importance of spiritual discipline” (1995, 134–137).

Christian spirituality can also be defined as “the disposition or internal condition of people when in such a state as prepares them to recognize and fully appreciate spiritual realities, and such true spirituality is ultimately the result of the inworking of the Holy Spirit (1 Cor. 2:14, 15; 3:1, 16—see Unger 1981, p. 1043)” (Tan 1987b, 36).

Evan Howard has recently provided a comprehensive description of Christian spirituality consisting of three levels: “the level of practice, which refers to our actual cultivation and experience of relationship with God; the level of dynamics, which refers to our formulation of the patterns of lived divine-human relationship; and the level of academic discipline, which refers to the formal field of study that explores the first two levels in a systematic manner” (2008, 24).

Christian spirituality, from a biblical and evangelical perspective, has many aspects and facets (see Tan 1987b, 36–38). First, it means having a deep hunger or thirst for God (Ps. 42:1–2; Matt. 5:6). The Holy Spirit inspires such a sincere longing to know God in a personal and intimate way (see Packer 1973). In every person, there is a God-shaped vacuum that only God can fill and fulfill.

Second, it means having a love for God based on personal knowledge of God, which eventually results in worship of God and obedience to his good and perfect will (Matt. 22:37–38; John 14:21, 23; cf. Rev. 2:1–7).

Third, it means being filled with the Holy Spirit and surrendering to God’s deepening work of grace in our hearts and not yielding to the sinful nature or the flesh in us (Eph. 5:18; Gal. 5:16; Rom. 6:12–13). The regular, grace-filled, nonlegalistic practice of the spiritual disciplines involving both individual and community life will help us connect more to the presence and power of the Holy Spirit (see Tan & Gregg 1997) and experience God’s deepening work of grace in transforming us to become more like Jesus. However, it is the Holy Spirit who transforms us into deeper Christlikeness (2 Cor. 3:18), and not the spiritual disciplines themselves.

Fourth, it means discovering and using the spiritual gifts given by the Holy Spirit for God’s purposes and glory (see Rom. 12; 1 Cor. 12; Eph. 4; 1 Pet. 4); bearing forth the fruit of the Spirit, which is ultimately agape or Christlike love (Gal. 5:22–23); and becoming more Christlike in every way in our lives and character (Rom. 8:29).

Fifth, it means developing biblical thinking and having a worldview that is consistent with God’s eternal perspective as revealed in the Bible, his inspired Word (cf. Rom. 12:2; Phil. 4:8; Col. 3:16a; 2 Tim. 3:16–17). Such biblical thinking will lead to a balanced ministry to the whole person, involving evangelism, missions, discipleship training including servanthood, leadership (see Tan 2006b, 2009b), pastoral care and counseling, social action, and an eschatological hope and longing for the Lord’s return and the final consummation of the kingdom of God (see also Tan 2019c).

Sixth, it means being involved in spiritual warfare, which requires the use of supernatural power and resources from God (cf. 1 Cor. 4:20; Eph. 6:10–18), especially the use of prayer and Scripture in the power of the Holy Spirit to overcome the world, the flesh, and the devil (Eph. 2:2–3). This will include the crucifixion of our own ministry and the surrendering of our ambitions to the service of Christ (Purves 2007), actualizing the truth that we have been crucified with Christ and that he lives in us (Gal. 2:20), leading to the resurrection of ministry and serving in the hope of the risen Lord (Purves 2010).

Finally, it means that there are mystical aspects and experiences in the depths of Christian spirituality, which transform us to be more Christlike, including sharing in the fellowship of Christ’s sufferings (Phil. 3:10). At times it may include experiencing the “dark night of the soul,” as described by St. John of the Cross (cf. Isa. 50:10) and discussed in chapters 17 and 18 of this book. It is important for Christian therapists, guided by the Holy Spirit through Scripture and writings on Christian spirituality, to understand such mystical and painful experiences of the spiritual life in Christ, so that clients can be better helped and empathically supported when they are going through dark nights. God uses these experiences to lovingly draw us away from the many distractions of our lives and closer to him so that he can work a deeper, inner transformation of the soul (see Foster 1978, 89–91). When helping clients who are experiencing such spiritual struggles, the Christian therapist, guided by the Holy Spirit, will learn that the best therapy is to provide empathic understanding, caring support, and much prayer (see Tan 1987b, 37).

Other aspects and dimensions of Christian spirituality center on loving God and loving others (Mark 12:29–31; see McKnight 2004; see also Augsburger 2006), but the major ones just described can help Christian therapists provide Christian counseling that also aims at spiritual growth and Christlike maturity in the client, Christian spiritual formation. Jeffrey Greenman has provided the following biblically based and theologically oriented succinct definition: “Spiritual formation is our continuing response to the reality of God’s grace shaping us into the likeness of Christ, through the work of the Holy Spirit, in the community of faith, for the sake of the world” (2010, 24).

In a similar vein, Parker has recently emphasized the crucial life-giving work of the Holy Spirit in the development of true Christian spirituality:

In the Old Testament, the dominant metaphor for the Spirit is ruach (wind, breath) and hence an early connection to the idea of the Spirit’s life-giving quality. . . . In the New Testament this metaphor of the Spirit (Greek: pneuma; cf. English “wind”) creating new life is addressed in the context of the regeneration of the believer (Rom. 8:11; 1 Cor. 6:11; Titus 3:5). St. Paul further connects the life-giving work of the Spirit to the transformation of the believer into the very image or likeness of Christ (2 Cor. 3:17–18). Thus, for Paul, the new life of the Christian can be characterized as one in which the old life of the “flesh” is exchanged for a new life dominated by the Spirit (Rom. 8). (2008, 286)

Christian Spirituality: Types and Approaches

While Christian spirituality can be defined and described to some degree (see Howard 2008; see also Scorgie et al. 2011), there are different types of, and approaches to, Christian spirituality.

One way of further elaborating on the types of Christian spirituality available to us is to focus on the six major traditions of Christian faith as streams of living water, as Richard Foster has done. He has described the following six traditions as essential to a balanced approach to Christian spirituality: the contemplative tradition, emphasizing the prayer-filled life; the holiness tradition, emphasizing the virtuous life; the charismatic tradition, emphasizing the Spirit-empowered life; the social justice tradition, emphasizing the compassionate life; the evangelical tradition, emphasizing the Word-centered life; and the incarnational tradition, emphasizing the sacramental life (see Foster 1998).

Similarly, Kenneth Boa (2020) has provided descriptions of twelve major biblical and practical approaches to spiritual formation, each focusing on a distinctive facet of Christian spirituality. They are (1) relational spirituality, focusing on loving God completely, ourselves correctly, and others compassionately; (2) paradigm spirituality, focusing on cultivating an eternal versus a temporal perspective; (3) disciplined spirituality, focusing on engaging in the historical disciplines; (4) exchanged-life spirituality, focusing on grasping our true identity in Christ; (5) motivated spirituality, focusing on a set of biblical incentives; (6) devotional spirituality, focusing on growing in relationship with God; (7) holistic spirituality, focusing on every component of life under the lordship of Christ; (8) process spirituality, focusing on process versus product, being versus doing; (9) Spirit-filled spirituality, focusing on walking in the power of the Spirit; (10) warfare spirituality, focusing on overcoming the world, the flesh, and the devil; (11) nurturing spirituality, focusing on a lifestyle of evangelism and discipleship; and (12) corporate spirituality, focusing on encouragement, accountability, and worship (see Boa 2020, contents).

Although certain varieties of Christian spirituality focus on becoming more mature in Christ, there are also personal preferences regarding how we approach God and develop our spiritual maturity. Spiritual temperaments also vary among us, with different preferences in spiritual pathways to God. Gary Thomas (2000b) has therefore emphasized that Christian spirituality is not “one-size-fits-all.” Instead, he describes nine sacred or spiritual pathways from which people may choose according to their preferences, in order to grow in Christ: tradition, vision, relationships, intellectual thought, service, contemplation, activism, nature, and worship. Acceptance of one another’s approach to Christian spirituality and spiritual formation in Christ is crucial. In such spiritual formation into deeper Christlikeness, the work of the Holy Spirit is essential, including spiritual formation that occurs in the context of Christian therapy (see, e.g., Coe & Hall 2010a; 2010b; also Chan 2020; Collicutt 2015; T. W. Hall & Hall 2021; Sandage et al. 2020).

Sidebar 19.1: Twelve Major Approaches to Spiritual Formation

(see Boa 2020)

1. Relational spirituality

2. Paradigm spirituality

3. Disciplined spirituality

4. Exchanged-life spirituality

5. Motivated spirituality

6. Devotional spirituality

7. Holistic spirituality

8. Process spirituality

9. Spirit-filled spirituality

10. Warfare spirituality

11. Nurturing spirituality

12. Corporate spirituality

Concluding Comments

In order for the Holy Spirit to do the crucial work in Christian therapy that also focuses on Christian spirituality and the spiritual formation of clients into deeper Christlikeness (Rom. 8:29), Christian therapists need to have faith in Christ as Lord of all professional and academic disciplines, including psychology and counseling (E. L. Johnson 1997). As Spirit-filled servants of Jesus Christ, Christian therapists will exercise faith or trust and full confidence in Christ as the master and maestro of our field and profession of counseling and psychotherapy (Tan 2008b; see also Willard 1998, 95; 2006).

Christian therapists who by faith practice a Christ-centered, biblically based, and Spirit-filled approach to counseling will experience and help their clients experience the eternal life that Jesus came to give us (John 3:16; 10:10). As Dallas Willard wrote:

Many counselors today are learning that for their own work, deep immersion in the disciplines is necessary, both for developing their own character, and beyond that, accessing special powers of grace for their work in counseling people. Many psychologists are learning how to use techniques of prayer and various kinds of ministry to have a much greater effect than they could have if all they had to go on were just the things they learned in their clinical training programs. . . . I think the most important and the most solid way is to begin to integrate prayer and spiritual teaching into the therapy process as it seems appropriate. . . . I think the issue here lies deeper than even matters of integration as we commonly discuss it. It is a matter of our understanding of the gospel of Jesus Christ as one which breaks through the natural world and brings it into the spiritual world and invites us as individuals to learn to live an eternal kind of life now. (1996, 19–20)

Several decades ago, Isaac Marks (1978) and Jerome Frank (1982), two prominent leaders in the field of secular psychotherapy, had already challenged therapy researchers to pay more attention to the role of “healing power,” or faith healing, involving faith and religious processes, in psychotherapy and its effects or outcomes. Further research is obviously needed (although there is now strong empirical evidence supporting the effectiveness of religious and spiritual therapies, including Christian therapies), focusing more specifically on religious and spiritual healing interventions, including inner-healing prayer, and their effectiveness, especially in Christian therapy conducted by Christian therapists, who are empowered by the Holy Spirit. We need to prayerfully depend on the Holy Spirit and the Spirit’s power and gifts and truth and fruit in order to be Spirit-filled servants of Jesus Christ in counseling and psychotherapy. The Holy Spirit will enable us to continue to develop and practice a truly Christian psychology that is biblically based. This endeavor will require involvement with a community of Christian scholars and Christian counselors and psychologists. Only by the grace of God will we thus keep the faith or be kept in the faith in him in our work in counseling and psychotherapy (see Tan 2008b, 67).

I would like to conclude this chapter by sharing parts of a personal letter I wrote at the end of an autobiographical chapter on my integration journey and reflections as a Christian psychologist and pastor (Tan 2010; see also Tan 1993, 2005), which was written in a more personal, relational, embodied, and communal context:

Dear Friend,

I would like to share with you some lessons that I have learned . . . in my integration journey so far as a Christian psychologist and pastor. . . .

First, I would recommend that you set as your priority your relationship with the Lord, that he will always be your first love (Rev. 2:4) and that you will love him with all your heart, soul, mind, and strength, and love your neighbor as yourself (Mark 12:29–31), . . . including a daily quiet time alone with the Lord . . . and periodic longer personal retreats with him.

Second, I want to thank God for the many mentors, formal or informal, whom he has graciously sent into my life. . . . I pray and wish for you to have a few good mentors, especially humble, loving, and Christlike Christian mentors, who will provide the loving support, intellectual stimulation, rigorous challenge, spiritual direction, and faithful prayers for you in your integration journey.

Third, there is much helpful literature that is now available on the integration of Christian faith and psychology, including therapy, that is essential reading for you. . . . In this regard, it is of ultimate importance and value to be saturated with Scripture as the inspired, eternal Word of God (2 Tim. 3:16).

Fourth, learn to be filled daily with the power and presence of the Holy Spirit (Eph. 5:18), by confession of sins and yielding to him and the Lordship of Christ. . . . Be prayerfully dependent on the Holy Spirit, who is the Counselor or Comforter par excellence (John 14:16–17), especially in clinical practice or therapy with clients, where his agape love can be manifested in a warm, empathic, and genuine therapeutic relationship with clients.

Fifth, be thankful for how we are wounded healers ourselves. . . . Remember that God can use your own sufferings and struggles to expand and deepen your capacity for empathy and compassionate caring (2 Cor. 1:3–4).

Finally, I would like to suggest that you do not make psychology, therapy, or even the integration task to be everything in your life. . . . Instead, seek the Lord and his kingdom first (Matt. 6:33) and always see the bigger picture of God’s will and God’s kingdom with loving obedience to him. . . . It includes enough time to reach out to others, especially the lost, the oppressed, and the broken—reaching out with the good news of Jesus Christ, who alone can ultimately save us all.

I would like to wish you the Lord’s best and deepest blessings, as you walk on with him in your integration journey. God Bless! (Tan 2010, 86–88)

Recommended Readings

Chandler, D. J. (Ed.). (2016). The Holy Spirit and Christian formation: Multidisciplinary perspectives. Cham, Switzerland: Springer/Palgrave MacMillan.

Fee, G. D. (1994). God’s empowering presence: The Holy Spirit in the letters of Paul. Peabody, MA: Hendrickson.

Foster, R. J. (2018). Celebration of discipline: The path to spiritual growth (special anniversary ed.). New York: Harper One.

Gilbert, M. G., & Brock, R. T. (Eds.). (1985). The Holy Spirit and counseling, Vol. 1: Theology and theory. Peabody, MA: Hendrickson.

Gilbert, M. G., & Brock, R. T. (Eds.). (1988). The Holy Spirit and counseling, Vol. 2: Principles and practice. Peabody, MA: Hendrickson.

Greenman, J. P., & Kalantzis, G. (Eds.). (2010). Life in the Spirit: Spiritual formation in theological perspective. Downers Grove, IL: IVP Academic.

Howard, E. B. (2008). The Brazos introduction to Christian spirituality. Grand Rapids: Brazos.

Levison, J. (2013). Inspired: The Holy Spirit and the mind of faith. Grand Rapids: Eerdmans.

Packer, J. I. (2005). Keep in step with the Spirit: Finding fullness in our walk with God (rev. ed.). Grand Rapids: Baker Books.

Scorgie, G. G., Chan, S., Smith, G. T., & Smith, J. D., III. (Eds.). (2011). Dictionary of Christian spirituality. Grand Rapids: Zondervan.

Sutton, G. (2021). Counseling and psychotherapy with pentecostal and charismatic Christians: Culture and research/ Assessment and practice. Springfield, MO: Sunflower.

Tan, S. Y., & Gregg, D. H. (1997). Disciplines of the Holy Spirit. Grand Rapids: Zondervan.

Thiselton, A. C. (2013). The Holy Spirit—In biblical teaching, through the centuries, and today. Grand Rapids: Eerdmans.

Vining, J. K. (1995). Spirit-centered counseling: A pneumascriptive approach. East Rockaway, NY: Cummings & Hathaway.

Chapters 20

Legal and Ethical Issues in Christian Counseling and Psychotherapy

Legal and ethical issues in the general field of counseling and psychotherapy have already been discussed in chapter 3. In this final chapter, the legal and ethical issues that pertain more specifically to Christian counseling and psychotherapy are discussed.

Legal issues involving the specific laws of a country, state, or province that are relevant to the professional practice of counseling and psychotherapy also apply to the professional practice of Christian therapy. Examples provided in chapter 3 in the context of American society include the prohibition of sex with clients; the requirement to protect client confidentiality (with a few exceptions relating to mandatory reporting laws, such as in cases of child abuse and elder abuse); the need to assure the competency of therapists in the professional services they provide; and the mandate to refrain from insurance fraud (see S. Knapp et al. 2007, 54). Christian therapists must be aware of laws that govern the professional practice of counseling and psychotherapy (see, e.g., Levicoff 1991; Ohlschlager & Mosgofian 1992). Since laws can be changed or revised, and new ones can be enacted, it is imperative for Christian therapists, like all therapists, to keep up to date regarding legal and ethical issues in counseling and psychotherapy. In many states in the United States, professional therapists are required to take a continuing education course in legal and ethical issues pertaining to their area of professional practice before they can be licensed or relicensed for independent practice.

The rest of this chapter focuses more on ethical issues and guidelines that apply to the practice of Christian therapy. These guidelines are discussed in the Y-2014 revision of the American Association of Christian Counselors (AACC) Code of Ethics first drafted by the AACC Law and Ethics Committee chaired by George Ohlschlager and made available in 2004 (see American Association of Christian Counselors [AACC] 2004). The complete 2014 AACC Code of Ethics can be reviewed or downloaded at http://www.aacc.net/about-us/code-of-ethics/. Ethical issues and challenges relevant to the incorporation of spirituality and religion into psychotherapy in general have also received increased attention in recent years (see, e.g., Gonsiorek et al. 2009; Hathaway & Ripley 2009; Plante 2007; see also Cashwell & J. S. Young 2020; Gill & Freund 2018; Hathaway 2013), including a proposed set of sixteen basic spiritual and religious competencies (three in the area of attitudes, seven in the area of knowledge, and six in the area of skills) for psychologists wanting to integrate spirituality and religion into counseling and psychotherapy (Vieten et al. 2013).

Sidebar 20.1: American Association of Christian Counselors Code of Ethics (Y-2014 Revision)

The AACC Code of Ethics is built on seven biblical-ethical foundations:

1st Foundation: Jesus Christ—and His revelation in the Old and New Testaments of the Bible as the inspired Word of God—is the preeminent model for Christian counseling practice, ethics, caregiving activities and the final authority for all matters about which it speaks.

2nd Foundation: Christian counseling maintains a committed, intimate, and dedicated relationship with the worldwide church, and individual counselors with a local body of believers.

3rd Foundation: Christian counseling, at its best, is a Spirit-led process of change, transformation, and growth, geared to help others mature in Christ by the skillful synthesis of counselor-assisted spiritual, psychosocial, familial, biomedical, and environmental interventions.

4th Foundation: Christian counselors are dedicated to Jesus Christ as their “first love,” to excellence in client service, to ethical integrity in practice, and to respect for everyone encountered.

5th Foundation: Christian counselors accord the highest respect to biblical revelation regarding the sanctity and defense of human life, the dignity of human personhood, and the sanctity of marriage and family life.

6th Foundation: The biblical and constitutional rights to Religious Freedom, Free Speech, and Free Association protect the Christian counselor’s public identity, and the explicit incorporation of spiritual practices into all forms of counseling and intervention.

7th Foundation: Christian counselors are mindful of their representation of Christ and His church as Ambassadors of Reconciliation and are dedicated to honor their commitments and obligations in all social and professional relations.

The Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC), a division of the American Counseling Association (ACA), has also developed and described The Competencies for Addressing Spiritual and Religious Issues in Counseling as guidelines for competent and ethical practice in spiritually and religiously integrated counseling in six major categories: (1) culture and worldview (2 guidelines), (2) counselor self-awareness (3 guidelines), (3) human and spiritual development (1 guideline), (4) communication (3 guidelines), (5) assessment (1 guideline), and (6) diagnosis and treatment (4 guidelines). These fourteen competencies are aspirational, and no therapist or counselor is expected to master all of them but should continue to grow in applying them in practice (see Cashwell 2018, xv–xvii; also Cashwell & Young 2020). More specifically, ASERVIC states four guidelines or competencies for diagnosis and treatment:

1. When making a diagnosis, the professional counselor recognizes that the client’s spiritual and/or religious perspectives can (a) enhance well-being; (b) contribute to client’s problems; and/or (c) exacerbate symptoms.

2. The professional counselor sets goals with the client that are consistent with the client’s spiritual and/or religious perspectives.

3. The professional counselor is able to (a) modify therapeutic techniques to include a client’s spiritual and/or religious perspectives, and (b) utilize spiritual and/or religious practices as techniques when appropriate and acceptable to a client’s viewpoint.

4. The professional counselor can therapeutically apply theory and current research supporting the inclusion of a client’s spiritual and/or religious perspectives and practices (Cashwell 2018, xvii).

AACC Code of Ethics: A Brief Review of the Y2014 Revision

A code of ethics can be defined as “a systematic statement of ethical standards that represent the moral convictions and guide the practice behavior of a group—in this case, the various counseling disciplines” (Ohlschlager & Clinton 2002, 245), referring to Christian and counseling ethics.

George W. Ohlschlager and Timothy E. Clinton also provided the following Christian counselor’s golden rule, based on Romans 13:8–10, to reflect the core values and rules of Christian counseling ethics:

Christian counselor, hear this:

· Do not be indebted to any client . . . except the debt to love them.

· For if you love your clients, you honor all your professional . . . duties.

You know the rules of counseling . . .

· Do not engage in any form of sexual misconduct with your clients, whether current or past.

· Do not, as far as it is possible with you, let them kill or harm themselves or anyone else.

· Do not steal your client’s money or disregard your time with them.

· Do not harm or envy or look down on or manipulate or fight with or in any way exploit those Christ has sent to you for help.

In fact, to sum it up and state it conclusively:

· Practice the Golden Rule with all wisdom and grace.

· Love your clients as yourself.

· Don’t do anything to your clients or those they love that you wouldn’t want done to yourself.

· For love does no wrong to any client. Therefore, to love your clients as Christ loves you is to fulfill all your obligations—all your moral-ethical-legal duties—as a Christian counselor. (2002, 247)

The crucial emphasis in Christian counseling ethics (see also Browning 2006; R. K. Sanders 2013; Tjeltveit 1992, 1999) is therefore to follow the biblical command to love one another with agape, Christlike love (John 13:34–35) and to love our neighbor as ourselves (Mark 12:31).

The 2014 revision of the AACC Code of Ethics or Y-2014 Code (see American Association of Christian Counselors 2014) has been reorganized with a significant formatting change from the original 2004 version. Ethical standards relevant to the entire range of counselors and helpers are first defined, followed by specific sections that relate first to licensed professionals and then to ministry-based helpers such as pastors, pastoral counselors, chaplains, and lay counselors or lay helpers. The Y-2014 code is still built on seven major biblical-ethical foundations (see sidebar 20.1). It is also mainly organized along eight core principles for ethical and Christ-centered practice in Christian counseling: compassion (a call to servanthood), competence (a call to excellence), consent (a call to integrity), confidentiality (a call to trustworthiness), cultural regard (a call to dignity), case management (a call to soundness), collegiality (a call to relationship), and community presence (a call to humility) (see also Tan & Scalise 2016, 215–220).

The following is a brief overview of the AACC Y-2014 Code of Ethics consisting of six major sections of ethical standards (see Table of Contents). The first section presents ethical standards for all Christian counselors: ES1-000: A Judeo-Christian worldview—practicing through faith and values (e.g., affirming human worth and dignity, an orientation of beneficence). ES1-100: Compassion in Christian counseling—A call to servanthood (e.g., no harm or exploitation allowed, refusal to participate in harmful activities of clients, sexual misconduct forbidden, caution on dual and multiple relationships). ES1-200: Competence in Christian counseling—A call to excellence (e.g., honoring the call to competent Christian counseling; duties to study and maintain expertise; maintaining integrity in work, reports, and relationships; duties to consult and/or refer; consultation practice; protective action when personal problems interfere). ES1-300: Consent in Christian counseling—A call to integrity (e.g., securing informed consent, consent in the structure and process of counseling, consent for biblical and spiritual practices in counseling, special consent for more difficult interventions, changes in the counselor’s role). ES1-400: Confidentiality in Christian counseling—A call to trustworthiness (e.g., maintaining client confidentiality, asserting confidentiality or privilege following demands for disclosure, protecting people from deadly harm [the rule of mandatory disclosure], disclosure for supervision, consults, teaching, preaching and publication, maintaining privacy and preserving written records). ES1–500: Cultural regard in Christian counseling—A call to dignity (e.g., affirming the worth and value of others, cultural competency, working with persons of different faiths, religions and values, cultural sensitivity, action if value differences interfere with counseling). ES1–600: Case management—A call to soundness (e.g., treatment planning, case notes and proper record-keeping, working with couples, families, and groups, continuity of care and service interruption). ES1-700: Collegiality in Christian counseling—A call to relationship (e.g., relationships in the professional and ministerial workplace, Christian counselors as employers and employees, base standards for educators and supervisors, specific standards for counselor education programs and counselor supervision programs). ES1-800: Community presence in Christian counseling—A call to humility (e.g., advertising and public relations, statements in public communications, communications of association with the AACC and other groups, communication of work products and training materials, ethical relationships with the state and other social systems, writing and publication ethics in Christian counseling, ethical standards for Christian counseling researchers).

The second section of the AACC Y-2014 Code of Ethics is on Use of technology and technology-related applications: ES2-000: Additional ethical standards in the use of technology (e.g., technology orientation). ES2-100: Core ethical standards in the use of technology (e.g., compassion, competence, consent, confidentiality, cultural regard, case management, collegiality, and community presence in technology applications). The third section of the Y-2014 Code of Ethics is on Additional ethical standards for licensed and professional Christian counselors: ES3-000: Fees, client billing and financial relationships. ES3-100: Third-party payers and managed-care entities. ES3-200: Testing, assessment, and clinical evaluation.

The fourth section of the AACC Y-2014 Code of Ethics is on Additional ethical standards for pastoral and lay Christian counselors: ES4-000: Definitions and roles of pastors and pastoral counselors (e.g., the pastor and pastoral counselor—ordained ministers of the gospel, rules of ethics code application and exemption, the use of fees or communicating false roles, aiding and abetting unauthorized practice). ES4-100: Definitions and roles of lay caregivers and non-ordained ministers (e.g., the lay caregiver and non-ordained ministers, rules of ethics code application and exemption, lay caregivers under supervision of the church, the use of fees or communicating false roles, aiding and abetting unauthorized practice).

The fifth section of the AACC Y-2014 Code of Ethics is on Standards for resolving ethical-legal conflicts: ES5-000: Base standards for ethical conflict resolution (e.g., base rules for resolving ethical-legal conflicts, attempting first to harmonize conflicting interests, when conflict cannot be harmonized). ES5-100: Resolving conflicts with employers and colleagues (e.g., ethical and value differences with employers and colleagues, Christian counselors working in public agencies, conflict resolution process with employers and colleagues, law and ethics violations by employers and colleagues). ES5-200: Resolving professional and organizational conflicts (e.g., the higher ethics of being a Christ follower, acting first to resolve conflict with church or profession, when ethical harmony is not reached). ES5-300: Resolving conflicts with the state and its laws (for examples, see ES5-200).

The final and sixth section of the AACC Y-2014 Code of Ethics is on Procedural Rules: PR6-000: Authority, jurisdiction, and operation of the AACC Law and Ethics Committee. PR6-100: General orientation to ethical enforcement. PR6-200: Credential holder, CCN (Christian Care Network) member and AACC response to LEC (Law and Ethics Committee) action. PR6-300: Procedures for the adjudication of complaints. PR6-400: Formal case review procedures. PR6-500: Formal appeal hearing procedures. PR6-600: Procedures following action by churches, courts, and other bodies.

This AACC Y-2014 Code of Ethics is a comprehensive and helpful one for Christian counselors and therapists to use, guiding them in their professional work, and for ministers and lay counselors in their helping ministries.

Ethical Issues and Guidelines for Integrating Christian Faith and Spiritual Direction into Psychotherapy

There are more specific ethical issues and guidelines that pertain to integrating Christian faith, including spiritual direction and spiritual disciplines, into psychotherapy (Tan 1994, 2003c, 2004; see also Hathaway 2009; Richards & Bergin 1997, 143–169; Richards & Bergin 2005; R. K. Sanders 2013).

The following potential pitfalls or dangers exist in religious psychotherapy, which includes integrating Christian faith and spiritual direction into psychotherapy.

1. Imposing the therapist’s religious beliefs or values on the client, thus reducing client freedom to choose

2. Failing to provide sufficient information regarding therapy to the client

3. Violating the therapeutic contract by focusing mainly or only on religious goals rather than therapeutic goals, and thus obtaining third-party reimbursement inappropriately. (It is, however, sometimes difficult to clearly differentiate between spiritual and therapeutic goals because they tend to overlap for religious clients.)

4. Lacking competence as a therapist in the area of converting client values ethically or conducting religious psychotherapy appropriately

5. Arguing over doctrinal issues rather than clarifying them

6. Misusing or abusing spiritual resources such as prayer and Scriptures, thus avoiding dealing with painful issues in therapy

7. Blurring important boundaries or parameters necessary for the therapeutic relationship to be maintained

8. Assuming ecclesiastical authority and performing ecclesiastical functions inappropriately when referral to ecclesiastical leaders may be warranted

9. Applying only religious interventions to problems that may require medication or other medical or psychological treatments (see Tan 1994, 390)

The ethical issue of whether it is appropriate to charge fees and receive third-party reimbursement for the use of spiritual disciplines and religious interventions in psychotherapy was raised by Mark McMinn and Barrett McRay (1997). They especially emphasized the need to obtain empirical support for the efficacy of spiritual interventions in therapy. Religious and spiritual therapies now have a solid evidence base for their effectiveness (see Captari et al. 2018; Hook et al. 2019). It is also important to keep intact the goal of helping to reduce the psychological distress of clients and not completely replace therapy with only spiritual direction (Tan 2003c). Therefore it is ethical to integrate Christian faith and spiritual direction and the use of spiritual resources into therapy if the client and the therapist share similar religious or spiritual beliefs, if the client has expressed a desire for spiritual interventions to be used in therapy and thus has given informed consent, and if there is a valid reason for using a specific spiritual intervention in therapy because it is relevant to the client’s clinical problem and will help to reduce the client’s psychological symptoms and distress (see A. A. Nelson & Wilson 1984).

In a case where a client still wants to continue to see the same therapist for only spiritual direction after the client’s psychological symptoms have been significantly reduced and therapy goals have been substantially achieved, then the Christian therapist has several ethical options from which to choose. First, the therapist can agree to continue to see the client for spiritual direction and growth, with the client paying for these sessions, with no third-party reimbursements. Second, the therapist can provide a few more sessions of spiritual direction to the client pro bono, free of charge. Finally, the therapist can switch to a suggested donation voluntarily made by the client, without any third-party reimbursements (see Tan 2003c). It may therefore be ethically simpler to integrate spiritual direction into lay Christian counseling because fees are not charged by lay counselors in such a context (Tan & Scalise 2016; see also Tan 1997a, 2013c).

P. Scott Richards and Allen E. Bergin (1997, 143–169) covered ethical guidelines and issues related to a theistic, spiritual approach to therapy (see also Richards & Bergin 2005). They dealt with five important difficult and challenging ethical issues: dual relationships (religious and professional), the danger of displacing or usurping religious authority, the danger of imposing religious values on clients, the danger of violating work-setting (church-state) boundaries, and the danger of practicing outside the boundaries of competence. They also mentioned two other significant concerns: becoming enmeshed in superstition and trivializing the sacred or numinous (see Tan 2003c, 16). Their many cautious but helpful ethical guidelines for dealing with these five major ethical issues will here be briefly summarized (see Tan 2003c, 17–18).

First, regarding the ethical issue of dual relationships, Richards and Bergin (1997, 147–148) recommended several ethical guidelines. They include the following recommendations: Therapist/religious leader dual relationships should be avoided as a general guideline. Consultation with a supervisor or professional colleagues should be sought and agreement obtained before a therapist becomes involved in a dual relationship with a client that the therapist has deemed is in the best interest of the client. The limits and risks of the dual relationship need to be clearly explained to the client. The therapist should continue to seek frequent consultation with professional colleagues or a supervisor and be ready to terminate the dual relationship and make a proper referral if the client appears to be harmed by the dual relationship. Proper and careful documentation is crucial in this situation.

Second, regarding the danger of displacing or usurping religious authority, Richards and Bergin (1997, 151–153) recommended several ethical guidelines for collaborating with religious authorities. They include the following considerations: A client’s religious or denominational tradition, if any, should be assessed by a therapist, and the question of whether a client views their religious leaders as potential sources of help must be clarified. If a client agrees and gives written informed consent, the therapist can contact the client’s religious leaders to consult with them and enlist their support in helping the client. This should be done with proper respect for and clear communication with the client’s religious leaders, as well as with appreciation for their help and cooperation. Before spiritual interventions (including spiritual direction and spiritual guidance techniques) are used in therapy, the therapist should also clearly communicate to the client that the therapist does not have any ecclesiastical authority over the client. Ecclesiastical functions to be performed only by the religious leaders of the client (e.g., hearing confessions and absolving sins) should not be usurped by the therapist. A client should feel that a particular spiritual intervention (e.g., use of prayer or religious imagery) is appropriate in therapy before it is used by the therapist. The therapist should not criticize a client’s religious leaders but instead inform the client that the therapist generally views religious leaders and communities as potential sources of help and support.

Third, regarding the danger of therapists imposing their religious values on clients, Richards and Bergin (1997, 158–159) recommended several ethical guidelines for respecting client values. They include the following suggestions: A therapist should respect a client’s right to have religious beliefs and convictions that are different from those held by the therapist. A therapist should therefore not attempt to proselytize or convert a client to the therapist’s own religious faith or denomination. A therapist can engage in open and honest discussion of the moral and spiritual dimensions and consequences of a client’s value choices and behaviors if the client is interested in pursuing such a discussion. However, the therapist should avoid arrogantly condemning a client’s choices or behaviors with which the therapist does not agree. When such value conflicts occur in therapy, the therapist can express personal views but should preserve the client’s right to have different values. The therapist also needs to assess with the client whether their value conflicts may have a negative effect on therapy and hence whether referral of the client to another therapist with more similar values may be the best option. Religious and spiritual goals should only be set and spiritual interventions used in therapy if the client is interested in such goals and interventions and informed consent is obtained from the client.

Fourth, regarding the danger of violating work-setting (church-state) boundaries, Richards and Bergin (1997, 162–163) recommended several ethical guidelines for respecting church-state boundaries: A therapist working in civic settings must comply with the policies and laws concerning the separation of church and state in such work settings. A therapist in a civic setting should not use spiritual interventions in such a way as to impose a certain religious tradition on a client. Instead, a therapist should work within a client’s value system as far as possible. Written consent from both supervisor and client should be obtained by the therapist before using religious or spiritual interventions in therapy. A therapist also must obtain written parental consent before using any spiritual or religious intervention in therapy with children or adolescents. A therapist working in public schools or other civic settings involving children or adolescents is advised not to use religious or spiritual interventions such as prayer with clients, discuss Scripture with them, or distribute religious literature for bibliotherapy.

Fifth and finally, regarding the danger of practicing outside the boundaries of competence, Richards and Bergin (1997, 166) recommended several ethical guidelines for education and training standards for professional therapists who want to use a theistic, spiritual approach in their therapeutic work (see also Cashwell & J. S. Young 2020; Gill & Freund 2018; Hathaway 2013). They include the following recommendations: A therapist should be trained in the foundations of multicultural counseling attitudes and skills (see, e.g., D. W. Sue et al. 2019; see also D. W. Sue et al. 2007; Whaley & Davis 2007). Relevant and helpful scholarly literature, including journals and books on religious and spiritual issues in therapy and on the psychology and sociology of religion, should be read by therapists who wish to use a theistic, spiritual approach to therapy. At minimum, such therapists should also attend a workshop or a course on religion, mental health, and spiritual issues in therapy, and take a class or read books on world religions. They should gain more knowledge of specific religions and spiritual traditions and practices that may often be encountered in therapy (see, e.g., Richards & Bergin 2014; see also Dowd & Nielsen 2006; Pargament, Exline, & Jones 2013; Pargament, Mahoney, & Shafranske 2013). A therapist must obtain supervision or consultation when first seeing a client from a religious or spiritual tradition that the therapist is not familiar with and involving issues that the therapist has not dealt with previously. Such supervision or consultation is also important when a therapist first begins to use religious or spiritual interventions, especially if they are new, untried ones, in therapy with clients.

The ethical guidelines recommended by Richards and Bergin (1997) are cautious and conservative, and not everyone will agree with all that they have suggested. For example, sometimes it is ethical for a Christian therapist to share their faith in Christ and the gospel if the client asks for such specific information and gives a full informed consent for the gospel to be shared. This may happen in the context of a client seeking meaning in life and an answer to fear of death—key existential questions and spiritual struggles that sometimes emerge in therapy. Although aggressive proselytization, or directive effort to convert the client to the therapist’s Christian faith, is not appropriate in therapy, as Richards and Bergin have declared, there is an ethically appropriate place for gentle, noncoercive sharing of the gospel when requested by a client who gives full informed consent to openly discuss the Christian faith.

Another example is the ethical concern raised by Richards and Bergin (1997) about dual relationships with the client on the part of the therapist. Great care and clinical caution should be exercised in engaging in dual relationships with clients, because clients may be potentially harmed by such relationships. However, there are ethical ways in which a therapist can enter into a dual relationship with a client, for the benefit of the client (see, e.g., Barnett 2007b; A. A. Lazarus 1994, 2007; A. A. Lazarus & Zur 2002). Furthermore, in the special case of lay or paraprofessional helping, dual relationships are usually acceptable in the context of peer or friendship counseling, in which peers help one another with their problems (see Tan & Scalise 2016). For example, peer helping can occur in schools or youth groups where teens counsel other teens who are acquaintances or friends (see Sturkie & Tan 1992, 1993).

Virtue Ethics: Focusing on the Character of the Christian Therapist

W. Brad Johnson (2007a) has emphasized virtue ethics, which focus more on the character and moral virtues of the therapist, rather than only principle ethics (Corey, Corey, & Callanan 2007; see also Corey, Corey, & Corey 2019), which focus on the ethical guidelines and rules governing right and appropriate behavior in specific clinical situations (see also Dueck 1995).

Sidebar 20.2: Virtues That Should Characterize the Christian Therapist

(From S. L. Jones et al. 1988; summarized in S. L. Jones & Butman 2011, 471–474)

Compassion as opposed to elitism

Servanthood as opposed to superiority

Community as opposed to isolation

Accountability as opposed to independence and autonomy

Transparency as opposed to impression management

Love as opposed to Rogerian positive regard

Stewardship as opposed to profit maximization

Holiness as opposed to anonymity or wholeness

Wisdom as opposed to mere secular brilliance

Integrity as opposed to mere ethical compliance (to ethical codes)

Above all, the key characteristic or virtue of the Christian therapist should be a true depth of spirituality centered in Christ and empowered by the Holy Spirit (see Tan 1987b).

Gary Collins (2007, 83–99) has provided several suggestions to help Christian counselors deal with legal, ethical, and moral issues in their practice in biblical and God-honoring ways, respecting the client as a person of worth and always seeking the client’s welfare. More specifically, Collins warns about the danger of falling into unethical and sinful sexual intimacies with clients. He recommends the following helpful means of counselor self-control: “spiritual protection; knowing one’s vulnerabilities; being aware of danger signals; setting limits; telling oneself the truth; finding support and accountability with others” (2007, 99).

Future Directions in Christian Counseling and Psychotherapy and Implications for Ethical Practice

In bringing this chapter and this book to a close, it is appropriate to look ahead into possible future directions in Christian counseling and psychotherapy and identify some of the implications for ethical practice in this field.

First, in a more general context, James R. Beck (2006) made several predictions about how the integration of psychology, including counseling and psychotherapy and Christian faith, may develop in the next fifty years. After providing brief snapshots of the state of psychology, theology, and integration in 1956 and in 2006, he courageously made snapshot predictions about their possible state in 2056.

More specifically in the area of integration, Beck made the following predictions for 2056:

1. Christian therapists will be challenged to widen their understanding of psychotherapy to include other modalities such as coaching, spiritual formation, and discipleship.

2. Theoreticians who work in the area of the integrative enterprise will make great progress in synthesizing what now seem to be distinct models of integration.

3. Christian psychology will display an increased need for sophisticated empirical research to undergird its efforts to deliver quality services. . . .

4. Christian integrators must upgrade the level of understanding and utilization of psychological science . . . in their work of integration.

5. Integrators must likewise upgrade the sophistication of the biblical and theological material they utilize in their work. (J. R. Beck 2006, 327–328, punctuation adjusted)

The need to stay abreast of the latest developments in psychology and theology in the integration enterprise as well as the need to obtain further empirical support for the effectiveness of Christian therapeutic approaches and interventions with more sophisticated outcome research (see Worthington 2006; see also Captari et al. 2018; Hook et al. 2019) are clear ethical challenges for integrators in the next few decades.

Second, Clinton and Ohlschlager (2006) also made several predictions more specifically about the future of Christian counseling, as the field matures. They include the following twenty-five trends:

1. A twenty-first-century code of ethics

2. Advocacy for the client and the marginalized

3. National credentialing

4. Academic and clinic accreditation

5. Lay helping ministry

6. Spiritual and relationship formation

7. Biblical and theological depth

8. e-Counseling and use of Internet technologies

9. Expanding cutting-edge modes of care

10. Interprofessional relations

11. Working with faith-based initiatives

12. Intensive care for counselors and pastors

13. Distance and online education

14. Continuing education and focused certificate programs

15. Doctoral programs for Christian counseling leaders

16. Heightened multicultural sensitivity

17. New and more refined research

18. Salt and light ministry

19. Glocalization (“thinking globally, acting locally”)

20. Flowering into a mature interdisciplinary profession

21. Theoretical integration reaching maturity

22. Integration with medicine and law

23. Brain imaging and neuroscience

24. Positive psychology movement

25. Spiritual hunger and the emerging church (see Clinton & Ohlschlager 2006, 33–35)

These are possible trends in the future of Christian counseling as the field matures. However, the need for high ethical and biblical standards is obvious as new strategies, practices, and other innovations are used, especially in technological areas. One example is e-counseling or telephone and internet therapy, also called telepsychology or teletherapy, which raises ethical and legal questions about issues such as confidentiality, helping suicidal or dangerous clients, and counseling clients from different states in the United States (Centore 2006; see also McMinn, Orton, & Woods 2008; Pierce, Perrin, & McDonald 2020; Weinberg & Rolnick 2020). Such telepsychology or teletherapy, with the provision of counseling and psychotherapy services online or by telephone, became not only a major option but also the only option for many Americans and others in need of mental health care, due to the COVID-19 pandemic in the United States and worldwide, with stay-at-home orders or lockdowns in many places in March 2020 and later. Even after this pandemic, telepsychology will remain a major part of mental health care for many people (see Greenbaum 2020; Gruber et al. 2021). Further research is also needed on the effectiveness of teletherapy, as well as its limitations. Systematic reviews so far have shown that teletherapy via video and telephone is effective for depression, anxiety, PTSD, and adjustment disorder (Varker et al. 2019), and for substance use, eating disorders, and emotional distress in children and adolescents (Sloane, Reese, & McClellan 2012). It has also been found to be essentially as effective as face-to-face therapy, with higher retention rates in a randomized trial of telephone-administered versus in-person CBT for depression (Mohr et al. 2012). The positive psychology movement in particular holds promise for further development in the Christian therapy context (see, e.g., Hart & Hart-Weber 2006; see also Hackney 2007). However, it also must be carefully and biblically critiqued because it can overemphasize strengths, virtues, and happiness, and then downplay the human capacity for sin and evil and the importance of godly sorrow and repentance (Tan 2006a, 2019c; Hackney 2021; see also S. Jones 2014; McMinn 2017). Clinton and Ohlschlager encouraged Christian counselors to see that “the door to the future is wide open to us as Christian counselors, but there are many challenges and adversaries. We must join hands now and go forward together” (2006, 35).

Finally, Collins similarly described ten counseling waves of the future that apply to the field of Christian counseling. They include the waves of technology, globalism, biotechnology, whole-brain thinking, postmodernism, change in spirituality, changing churches, changing professionalism, nontraditional education, and positive psychology (2007, 849–861). Again, there is a need for clear and high standards of ethics and biblical values to guide Christian counselors and therapists in the years ahead as they navigate such significant waves of change in the counseling field.

Twelve emerging directions for the general field of psychotherapy have also been described by James Prochaska and John Norcross in the following areas:

1. Economics of mental health care or the industrialization of mental health care

2. Evidence-based practice

3. Therapy relationship

4. Technological applications

5. Self-help resources

6. Neuroscience

7. Personalized psychotherapy (including religious accommodative therapies)

8. Well-being (including positive psychology and executive coaching)

9. Combined psychotherapy and pharmacotherapy

10. Integrative health

11. Proactive treatment of populations

12. Effectiveness of psychotherapy (2018, 443–455)

The future of Christian counseling and psychotherapy therefore looks bright and promising, as spiritually or religiously oriented therapy in general continues to grow and develop in the coming decades. The challenge for Christian counselors and therapists is to remain faithful and fruitful in Christ, by the power of the Holy Spirit and the grace of God. Christian therapy must always be Christ centered, biblically based, and Spirit filled (Tan 1999b, 2001b), whatever the waves of change may be in the counseling and psychotherapy field in the years to come. We should regard these possible future directions with humility and some tentativeness, because only God knows the future with certainty. Christian therapy must also be ethically characterized by agape, Christlike love (Mark 12:31; John 13:34–35), upholding the highest of biblical virtue ethics, manifested as the fruit of the Holy Spirit (Gal. 5:22–23).

Recommended Readings

American Association of Christian Counselors. (2014). AACC code of ethics: Y-2014 code of ethics. Retrieved from http://www.aacc.net/about.us/code-of-ethics/.

Browning, D. S. (2006). Christian ethics and the moral psychologies. Grand Rapids: Eerdmans.

Cashwell, C. S., & Young, J. S. (Eds.). (2020). Integrating spirituality and religion into counseling: A guide to competent practice (3rd ed.). Alexandria, VA: American Counseling Association.

Gill, C. S., & Freund, R. R. (Eds.). (2018). Spirituality and religion in counseling: Competency-based strategies for ethical practice. New York: Routledge.

Levicoff, S. (1991). Christian counseling and the law. Chicago: Moody.

Ohlschlager, G. W., & Mosgofian, P. (1992). Law for the Christian counselor. Dallas: Word.

Richards, P. S., & Bergin, A. E. (2005). A spiritual strategy for counseling and psychotherapy (2nd ed.). Washington, DC: American Psychological Association.

Sanders, R. K. (Ed.). (2013). Christian counseling ethics: A handbook for therapists, pastors, and counselors (2nd ed.). Downers Grove, IL: InterVarsity.

Tjeltveit, A. C. (1999). Ethics and values in psychotherapy. New York: Routledge.

Weinberg, H., & Rolnick, A. (2020). Theory and practice of online therapy: Internet-delivered interventions for individuals, groups, families, and organizations. New York: Routledge.