Integrating spiritual direction functions in the practice of psychotherapy.

Recent research and clinical experience suggest that clients are increasingly expecting that psychotherapists will deal with their spiritual concerns that are traditionally addressed in spiritual direction. This expectation has already begun to impact the practice of psychotherapy by increasing interest in the "spiritually-oriented-psychotherapies." This article proposes that psychotherapy can become more receptive and effective in dealing with spiritual concerns by appropriately incorporating some or many of the functions of spiritual direction. The practice of spiritual direction is first described and compared to pastoral counseling and spiritually-oriented psychotherapy. Then eight functions of spiritual direction are presented and compared to similar "functions" in psychotherapy. Finally, specific recommendations for incorporating these functions into the practice of psychotherapy are discussed.

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Believing that spirituality is vital for growth and essential for dealing with life's problems, many individuals are pursuing a journey of spiritual growth. Pursuing this journey typically involves a commitment to engaging in spiritual practices such as prayer and meditation. As a result of this pursuit, some are finding their lives are more centered and fulfilling, whereas others are finding themselves trapped in old feelings, attitudes, and habits that appear to undo their progress. Even those who have made progress on the journey often encounter spiritual and psychological roadblocks to growth.

But fewer are approaching the institutional church for help with these concerns. Why is this? Presumably because of "spiritual homelessness," that is, the experience of no longer feeling 'at home' in one's religious traditions or with ministry personnel (Steere, 1997). Similarly, Jean Stairs (2000, p. 3) describes this phenomenon as "(t)he world is crying out for the church to be more the like the church, to represent the space and place where holiness, meaning, and God can be found, experienced, understood, and reimagined." Because of the extent of spiritual homelessness, it should not be surprising that many are turning to psychotherapy rather than to ministers for spiritual advice. It should also be noted that those who are already in psychotherapy expect that therapy will focus on their spiritual concerns (Westfeld, 2001).

These observations raise a number of questions. Are spiritual concerns appropriate and proper for psychotherapy? Shouldn't these individuals be seeking spiritual direction or pastoral counseling instead? Can psychotherapy become more receptive to these spiritual concerns? If so, how?

The article attempts to address these questions. It begins by differentiating psychotherapy from spiritual direction and pastoral counseling. It then describes eight process functions in spiritual direction and compares them with similar functions in psychotherapy. Next, the discussion turns to ways of integrating the spiritual direction functions into the practice of psychotherapy. Finally, three perspectives and two strategies for integrating the spiritual direction functions are discussed.

SPIRITUAL DIRECTION, PASTORAL COUNSELING, AND SPIRITUALLY-ORIENTED PSYCHOTHERAPY

Like spiritual direction, pastoral counseling and spiritually-oriented psychotherapy can and do address spiritual concerns and issues. Beyond this shared commonality, these three modalities differ with regard to type of clientele served, goals and purposes, the nature of the relationship with the professional, and the type of interventions utilized. A brief description of the practice of spiritual direction, pastoral counseling, and spiritually-oriented psychotherapy is provided in this section. Each of the three modalities will be discussed in terms of likely clientele, goals, type of relationship, and preferred interventions. Also included is a description of the training and professional organizations supporting each modality.

Spiritual Direction

Spiritual direction is also known as spiritual guidance, spiritual friendship, and spiritual companionship. There are various ways of defining spiritual direction in the Christian tradition. Definitions span the gamut from "spiritual direction is the application of theology to life of prayer" (Thornton, 1984, p. 1) to "spiritual direction, or the cure of souls, is a seeking after the leading of the Holy Spirit in a given psychological and spiritual situation" (Leech, 1977, p. 34). It is noteworthy that two of the themes, that is, "life of prayer" and "seeking after the leading of the Holy Spirit," are reflected in many descriptions of spiritual direction.

The clientele that may be most responsive to spiritual direction are typically relatively healthy spiritual seekers. Nevertheless, spiritual direction is quite inclusive and many spiritual writers contend that spiritual direction is appropriate for most Christians. However, there are some who would limit spiritual direction to those who possess a moderate degree of psyehologieal health and well-being (May, 1992).

Unlike psychotherapy and pastoral counseling which focuses more on symptom reduction or problem resolution, spiritual direction focuses more on the maintenance and development of spiritual health and well-being. More specifically, the basic goal of spiritual direction is to develop the directee's relationship with God. Because prayer is critical to this relationship, the directee's prayer life is a major consideration. This includes both discursive and meditative or centering prayer.

Spiritual direction involves a trained director who guides or companions another person-often called a "directee"--listening to that person's life story sensitive to the movement of God in the directee's daily life. The relationship that develops in spiritual direction differs from the type of relationship that is established in psychotherapy and pastoral counseling. For one, the relationship in Christian spiritual direction is triadic, involving the director, the directee, and God or the Holy Spirit. For another the relationship between directee and director is primarily one of mutual collaboration.

Interventions in spiritual direction include instruction in prayer and the prescription of rituals and other spiritual practices. When indicated spiritual directors may refer directees with certain psychological problems for concurrent psychotherapy or will suspend spiritual direction until the course of therapy is completed (Culligan, 1983). Whether one professional can effectively and appropriately provide both spiritual direction and either psychotherapy or pastoral counseling is a matter of considerable debate (May, 1992).

What training and level of certification is required of spiritual directors? Currently, there is no set educational and experience requirements, nor certification for the practice spiritual direction. Some contend that spiritual direction is a vocation rather than a profession; a special calling for which formal coursework and supervision is not essential. Others contend that specialized training in selected areas of theology and psychology are helpful and essential. Accordingly, there are a number of formal graduate training institutes and programs in spiritual direction (e.g., Shalom Institute and the Institute for Psychospiritual Health), but no universally recognized certification or licensure for spiritual directors. As a specialty, spiritual direction is now in a stage of expansion and professionalization. Spiritual Directors International is an ecumenical professional organization for spiritual directors, which claims a world wide membership of 3,500 members. It has begun publishing its own professiona l journal, Presence, and has recently ratified a set of ethical standards and guidelines for the practice of spiritual direction (Lescher, 1997).

Pastoral Counseling

Currently, two forms of pastoral counseling are practiced: a brief, time-limited form that is problem-solving or solution-focused, and a long-term form that is often psychoanalytically-oriented that focuses on personality change (Stone, 1999). Clergy and other ministry personnel who have some training in pastoral care and counseling provide a majority of short-term pastoral counseling. However, ministry personnel and others with formal supervised training in counseling and psychotherapy and who are certified and/or licensed can practice what is called pastoral psychotherapy. Pastoral psychotherapy is variously defined but tends to involve longer-term therapy, and in some instances is difficult to distinguish from psychotherapy (Wise, 1983).

Clientele for pastoral counseling are typically troubled individuals presenting with life transitions, emotional or relational crises, or because of guilt, abuse, addictions, or low self-esteem. Pastoral counseling is well suited for such crises and concerns, and is a unique form of counseling which uses religious and spiritual resources as well as psychological understanding for healing and growth.

The primary goal of pastoral counseling is symptom relief, problem resolution, and restoration of psychological health. Personality change is not usually a goal of pastoral counseling. However, as in secular psychotherapy, personality change is typically a goal of pastoral psychotherapy.

The relationship that develops between client and pastoral counselor varies. It some instances the pastoral counselor takes on the expert role and offers interpretations or advice. In other instances, the relationship is one of mutual collaboration, the relationship style commonplace in spiritual direction.

Treatment interventions usually include active listening and other problem solving or solution-focused counseling methods. It may also include advice on religious or spiritual matters, (e.g., forgiveness). Unlike spiritual direction, pastoral counseling typically does not bring to bear the resources of the client's faith community for healing, growth, or integration. Furthermore, pastoral counselors are likely to refer clients with certain presentations for psychotherapy.

Like spiritual direction, pastoral counseling is currently preoccupied with becoming a recognized profession. This means that issues of training, certification, and professional identity are central concerns. An increasing number of pastoral counselors are licensed to practice, usually in one of mental health specialties (e.g., licensed professional counselor) and certification is available from the American Association of Pastoral Counselors. This professional organization represents 3,000 pastoral counselors and is actively exploring ways of incorporating a focus on spiritual concerns and spiritual direction methods into the practice of pastoral counseling. While some are wary of extending the scope of pastoral counseling, citing major differences in epistemological perspectives and praxis stances between the two fields, others are supporting this extension (Galindo, 1998). Needless to say, the identity of pastoral counseling is significantly impacted by such forces as managed behavioral health care and the increasing numbers of spiritual directors and mental health counselors who compete for many of the same clients as pastoral counselors (Stone, 1999).

Spiritually-Oriented Psychotherapy

Spiritually-oriented psychotherapy is a broad characterization for a variety of psychotherapeutic approaches that are sensitive to the spiritual dimension. These approaches range from non-Christian approaches, transpersonal psychotherapies (Cortright, 1997; Karasu, 2000) to theistic (Richards & Bergin, 1999) and various Christian approaches (Benner, 2002; Propst, 1996; Sperry, 1998, 2001; Steere, 1997). Despite considerable variability among these approaches, some general observations about typical clientele, goals, and purposes, the nature of the relationship with the professional, and the type of interventions utilized in spiritually-oriented psychotherapy are possible.

Individuals seeking spiritually-oriented psychotherapy range from relatively healthy spiritual seekers to disordered clients presenting with symptomatic distress and/or impairment in one or more areas of life functioning.

The goals of treatment vary according to client presentation and need. They may include help with spiritual emergencies, the process of spiritual growth, increased psychological well-being, self-fulfillment or individuation, or the reduction of symptomatic distress and the restoration of baseline functioning.

The therapeutic relationship typically involves mutual collaboration. Not surprisingly, those practicing spiritually-oriented psychotherapy presumably will demonstrate respect for the client's spiritual values and concerns.

Various psychotherapeutic interventions are utilized depending on client need and indication. If indicated, referral for a psychiatric evaluation for medication or hospitalization may occur. Spiritual interventions are also involved. These include spiritual practices, such as prayer and meditation, and when indicated, collaboration or referral to clergy or chaplain.

One example of a Christian approach to spiritually-oriented psychotherapy can be briefly described. Sperry (1998) describes spiritual counseling as an approach similar but distinct from traditionally-practiced psychotherapy and spiritual direction. In this approach the clinician functions as both psychotherapist and spiritual guide simultaneously. Spiritual counseling addresses a wide range of psychological and spiritual concerns of clients. It is based on a composite developmental and pathology model of health and well-being, and it views growth in a holistic fashion including the psychological, moral, somatic, and spiritual dimensions. Because of its holistic focus, special attention is directed to a comprehensive assessment of the client's overall health status, psychological strengths and defenses, and moral and spiritual development considerations. Spiritual considerations include relationship with God, God-image or representation, as well as the individual's prayer life and spiritual practices as well a s involvement in a faith community and the type and level of support it provides. The specific goal is to promote the process of transformation in all its spiritual, psychological, moral, and somatic dimensions. Various psychotherapeutic and spiritual modalities, including spiritual disciplines such as prayer and meditation, are utilized to achieve this goal.

SHOULD PSYCHOTHERAPY BE RESPONSIVE TO SPIRITUAL ISSUES?

Unlike data on membership in professional spiritual direction and pastoral counseling organizations, there are no firm estimates on the number of professionals practicing spiritually-oriented psychotherapy. There are approximately 500,000 practicing psychotherapists (psychologist, social workers, psychiatrists, marital and family therapists, and mental health counselors, etc.) in the U.S. If even a small percentage of these psychotherapists chose to practice some form of spiritually-sensitive psychotherapy, there would be considerably more psychotherapists available to practice spiritually-sensitive psychotherapy than there are available spiritual directors. The phenomenon of "spiritual homelessness" may further limit individuals from seeking spiritual guidance from spiritual directors with institutional (i.e., church) ties. Even if pastors were to wholeheartedly embrace the role of spiritual counselor (Stairs, 2000), it is unlikely that they could be expected to deal adequately with complex spiritual matters involving psychological features (i.e., psychospiritual issues).

Accordingly, individuals seeking spiritual advice are likely to have greater access to spiritually-sensitive psychotherapists than to spiritual directors, and they can expect that psychotherapists who are sensitive to spiritual issues will have more specialized training in dealing with complex psychological problems that have spiritual aspects than most spiritual directors. Because they may be better equipped to handle many psycho-spiritual matters, spiritually-sensitive psychotherapists have a distinct advantage over spiritual directors without formal training in psychotherapy. This factor cannot be underplayed for individuals who have experienced early life traumas, substance or drug histories, or significant stressors and conflicts in their life and who are seeking spiritual advice. Thus, it does not seem unreasonable to conclude that psychotherapists sensitive to the spiritual dimension and with adequate training (1) could reasonably address the spiritual concerns of their clients.

But how can the practice of psychotherapy become more receptive and effective in dealing with spiritual issues and concerns? The article proposes that psychotherapy can become more receptive and effective by incorporating some or all of the functions of spiritual direction.

THE FUNCTIONS OF SPIRITUAL DIRECTION

There are various functions performed by or involving the spiritual director and the directee. Eight such functions, some of which have their counterparts in psychotherapy, are described in this section. Table 1 lists these functions.

Spiritual Assessment

The purpose of the spiritual assessment is to understand a client's spiritual experiences and spiritual orientation and beliefs. Even though spiritual experience is the core dynamics in spiritual direction, it is valuable to understand how an individual's beliefs may impact their experience of God in their lives and situations. For that reason the spiritual assessment elicits both experiences and beliefs. A useful beginning question is: "Can you tell me a little about your religious beliefs and feelings?" (May, 1992, p. 204). This can be followed up with questions that elicit the individual's specific experience of God, prayer, etc. Some spiritual directors conduct a formal spiritual history as part of this assessment. It might include the directees' religious upbringing, their images of God, their basic values and beliefs, their involvement in a spiritual community, and the place of prayer and other spiritual practices in their lives. The concomitant of the spiritual assessment in traditional psychotherapy i s the initial intake evaluation in which the client would be queried about presenting problem, past history of symptoms and treatments, social and developmental history, sexual and work history, health status, etc.

At the outset of spiritual direction, some directors inform the directee that an evaluation of the relationship with the director and progress in spiritual direction is usually made after about six months (Edwards, 2001). The following queries might be discussed at that time. These include: (a) how is grace manifesting itself in the relationship; (b) what is it about how the director reflects, questions, prays, and is silent that assists or hinders the directee's presence to God; and (c) whether it feels appropriate and right to continue the direction relationship (Edwards, 2001, p. 121).

Differentiating Spiritual Experience From Psychopathology 

There can be some unusual and troubling spiritual experiences associated with the spiritual journey, and clinicians are faced with the prospects of differentiating such spiritual experiences from major psychopathology. Spiritual emergency is a term for describing how the self becomes disorganized and overwhelmed by an infusion of spiritual energies that it is unable to integrate.

The term spiritual emergency was coined by Grof and Grof (1989) to identify the psychological difficulties encountered by Americans who engaged in eastern meditative practices in the 1960s. New realms of spiritual experiences can appear suddenly and dramatically leading to immense confusion, anxiety, and sometimes impaired functioning. Such individuals, who may have no obvious personal vulnerability or family history of mental illness, may wonder if they are experiencing psychosis or psychotic-like symptoms. Not surprisingly, mystical experiences such as visions have misdiagnosed as psychosis just as the "dark night" experiences have been misdiagnosed as depressive disorder. A phenomenon known as "the awakening of kundalini" may be the most commonly reported unusual spiritual experience (Grof & Grof, 1989). It is a form of energy residing in the body's energy centers or chakras that is activated by meditation or other spiritual practices. The energy flow may be gentle or overwhelmingly intense and can result in visions, widening of consciousness, clairvoyant perception, or frightening involuntary spasms, jerking, or repetitive movements. Since it tends to be misdiagnosed as mania, an anxiety disorder, or conversion disorder, it is essential that clinicians are aware of its manifestations. The function of differentiating spiritual experiences from psychopathology in spiritual direction is akin to the function of differential diagnosis in psychotherapy and psychiatry.

Transformation

Transformation is perhaps the central issue and goal of spiritual direction (Gratton, 1992). Transformation is the process of undergoing a radical change of mind and heart, a dying to the false self, and a continually assenting to one's true self, which reflects the image and likeness of God. Transformation is a life long process. In comparison, the goal or goals of psychotherapy are more circumscribed. They may be limited to symptom resolution or increased functioning, or more extensive such as personality change.

Fostering the Relationship Between God and the Directee

Spiritual direction is one means of developing one's relationship with God. Essentially, spiritual direction is a relationship among three persons: God, the directee, and the director. The relationship between the directee and the director can be instrumental "for the development of the relationship of the directee and God," but the later relationship exists prior to and is independent of the former. "Directors do not create relationships between God and their directees; they try to foster such relationships" (Barry & Connolly, 1982, p. 29). In short, while there are some obvious similarities between the establishment of a therapeutic alliance between client and psychotherapists in psychotherapy and fostering the relationship in spiritual direction, there is an obvious difference.

Advisement 

To foster its goal of transformation, spiritual direction focuses on advising the directee about "the life of prayer" and the use of spiritual practices (Edwards, 2001). Advice and instruction on prayer and meditation are key methods of spiritual direction. Typically, such advice arises out of questions and concerns initiated by the advisee. In the context of mutual collaboration, advisement comes in the guise of suggestions rather than firm directives. The closest analogue to advisement in psychotherapy are clinical interventions such as interpretation, cognitive restructuring, "homework," and, of course, advice-giving. Spiritual practices are commonly discussed and prescribed in spiritually-oriented psychotherapies.

Discernment

Discernment is the function of spiritual direction concerned with "seeking after the leading of the Holy Spirit." In the past, directors typically discerned "spirits" and major life decisions for their directees of course (Conroy, 1995; Thornton, 1984). Edwards (2001) notes that discernment in the "Roman Catholic, Anglican and mainstream Protestant church practice of spiritual direction today. . . has shifted the director to the directee, or to a kind of mutual discernment between them" (p. 68). Now, directors "listen with the directee for what God's Spirit seems to be up to, asking probing questions, perhaps offering suggestions, and above all providing a supportive, prayerful presence for deep listening. They see themselves as co-discerners with the directee" (Edwards, 2001, p. 69). While there is no direct analogue in psychotherapy to the process of discernment in spiritual direction, the phenomenon of "mutual collaboration" in making decisions about treatment is tangentially related, but does not, of cour se, involve the key element of seeking the Spirit's leading. Clinical case formulation is an even more distant analogue.

Dealing with Resistance

Three forms of resistance in spiritual direction have been noted: resistance to spiritual experience, resistance to the spiritual director or to spiritual direction, and the director's resistance to their directees or their religious experience (Ruffing, 2000). Each will be briefly described in this section.

The first form of resistance involves avoidance of religious or spiritual experience itself. Since spiritual direction primarily involves the directee's relationship with God, this form of resistance involves the directee's movement away from God's in-breaking in her life because of fear. This fear might be the intensity of God's presence, a perceived threat to her self-image, some change in her prayer experience, or the anticipation that an unpleasant consequence will follow.

According to Ruffing (2000), resistance to prayer is probably most common. The directee may have difficulty establishing a regular discipline of prayer or experience unpleasant memories or affects while engaging in meditation. The particular form of resistance "in directees depends on their psychological makeup and the particular psychological defenses they habitually employ in other areas of their lives" (p.41).

The second form involves resistance to the spiritual director or to spiritual direction. It may develop in response to the director's skill or presence (e.g., ineptitude, lack of attentiveness, judgmental attitude, or abusiveness). The director's timing or manner of questioning or reflecting the directee's concern or experience may be off on a particular day, or the overall interpersonal chemistry between the two may underlie the resistance. The result is that directees become averse to sharing their intimate experiences of and response to God fearing they will be controlled, misunderstood, or judged by the director. Furthermore, such resistance to spiritual direction is the most common reason for premature terminations.

Ruffing contends that resistance in spiritual direction is far less likely to be related to the director's skill than is resistance in psychotherapy, which more often reflects the therapist's skill. Rather, she notes that resistance in spiritual direction is more related to the directee's avoidance of spiritual disciplines, such as prayer and meditation. This "avoidance has nothing with the director's skill or presence. Rather, these directees avoid the qualitative commitment to spiritual growth that ongoing spiritual direction facilitates. Some directees slow down their own process by withdrawing from spiritual direction" (Ruffing, 2000, p. 45).

The third form involves the director's avoidance of something in the spiritual direction itself. This can take a number of forms such as dreading dealing with an issue that must be confronted and then forgetting the appointment or arriving late; or the director may be discouraged at the directee's lack of progress. Ruffing notes that avoidance of the "directee's religious experience comprises an even more serious form of resistance" (2000, p. 47). Perhaps the director is experiencing a "dark night" and the directee wants to share highly positive experiences, or maybe the director is frightened by or unsure how to respond to the directee's mystical experience or imagery. Sometimes, such resistance is part of the director's counter-transference.

Dealing With Transference and Counter-transference

Does transference occur in spiritual direction and if so how? Transference is a specific kind of unconscious projection of the directee's positive or negative expectations onto the director. Since spiritual direction tends to be scheduled monthly where- as dynamically-oriented psychotherapy might meet twice weekly, directors may assume that because it is less intensive, transference is unlikely to develop in spiritual direction. Because spiritual direction focuses primarily on the directee's relationship with God rather than with the director, directors may seldom need to engage transference directly. Nevertheless, the reality is that transference does occur in spiritual direction, even though the director may not be sufficiently trained to recognize and deal with it. Any directee "is susceptible to bringing unresolved emotional conflicts to the spiritual direction relationships and reenacting them in this new setting" (Ruffing, 2000, p. 158-159). "When the relationship between the director and direction--instead of the directee's relationship with God--becomes the focus . . . the entire process of spiritual direction can become sidetracked" (Ruffing, 2000, p. 162).

Ruffing (2000) describes four transferences unique to spiritual direction: (a) the directee idealizes director who is perceived as embodying spiritual qualities to which the directee aspires; (b) the directee develops an erotic attraction to the director based on their soul-friendship; (c) the directee symbolically views the director as representing God; and (d) the directee forms an institutional transference to the director (i.e., identifies the director with a particular religious denomination or institution; pp. 169-179).

It shouldn't be surprising that counter-transference also occurs in spiritual direction since counter-transference is elicited by the directee and is reciprocal. We noted earlier that director resistances in spiritual direction are part of the director's counter-transference. Needless to say, managing transference and counter-transference in spiritual direction requires considerable skill. Those practicing spiritual direction who also have formal training in psychotherapy presumably have an advantage in dealing with such transferences. Through supervision and psychological consultation, directors with less training and experience can learn to manage transference and their own reactions to directees.

INTEGRATING THE SPIRITUAL DIRECTION FUNCTIONS IN PSYCHOTHERAPY

Incorporating or integrating the spiritual dimension functions into the process of psychotherapy may seem rather straightforward and uncomplicated. On first reflection it would seem no different than adding a relapse prevention component to a cognitive-behaviorally oriented psychotherapy. If spiritually-oriented psychotherapy only involved the addition or incorporation of a spiritual assessment and spiritually-oriented therapeutic interventions or spiritual interventions (i.e., spiritual practices or disciplines) it would probably present few difficulties or challenges. However, incorporating the spiritual direction functions requires some major changes in the therapeutic process. These changes involve not just different types of interventions, but differences in relationship, focus, and stance. Not only is the working relationship in spiritual direction triadic instead of dyadic as in psychotherapy, the spiritual director is a companion or fellow traveler on the same spiritual journey as the directee. In ter ms of focus, spiritual direction's focus on prayer and the directee's ongoing relationship God is considerably different than a psychotherapeutic focus on symptoms, problems, or personality change.

Even more different is the stance or disposition of the director as compared to that of the therapist. The therapist's stance which is supportive and analytic--particularly in dynamically-oriented psychotherapies--and operates in a reflection/clarification/confrontation/interpretation mode with the goal of curing the individual (i.e., "restoring efficient functioning and increasing well-being;" May, 1992, p. 209). On the other hand, the spiritual director's stance is more one of quietly waiting and listening for the movement of the Spirit in pursuit of the goal of healing the individual (i.e., "increasing love;" May, 1992, p. 210). In other words, the director's stance is more at the "being" end of the being--doing continuum, whereas the therapists stance is more toward the "doing" end. The tempo in direction is more relaxed and essentially free of utilization review provisions so prevalent today in psychotherapy (i.e., meeting specific therapeutic objectives within a given number of authorized sessions).

PERSPECTIVES ON INTEGRATING THE SPIRITUAL DIRECTION FUNCTIONS

Beyond these relationship, focus, and stance differences is the basic question of whether or not the spiritual direction functions should be incorporated within psychotherapy. There are three different perspectives or points of view on this question that deserve careful consideration. The three are the positive perspective, the negative perspective, and the negotiated perspective.

The "positive perspective" endorses the incorporation of many or all of the spiritual direction functions being incorporated. This perspective is advocated by practitioners and supporters of the various spiritually-oriented psychotherapies. The transpersonal psychotherapies, in particular, espouse the belief that the therapeutic relationship is the ideal context for dealing with both the spiritual and psychological dimensions, whether simultaneously or sequentially (Cortright, 1997). It is notable that training, prescribing, and advising about meditation, among other spiritual practices, in the context of psychotherapy has been normative for most transpersonal psychotherapies over the past four decades. While many of these transpersonal approaches are not overtly Christian in their orientation, these approaches appear to have successfully and effectively combined many or all of the spiritual direction along with the psychotherapy functions within the role of the spiritually-oriented psychotherapist. While the ir clients may also be involved with a meditation teacher or group, many, if not all, of the spiritual direction functions are performed by their psychotherapists.

The "negative perspective" is championed by Gerald May who is both a psychiatrist and spiritual director. He has definite opinions about the roles and functions of spiritual direction and psychotherapy, and he refrains from combining the two roles or functions in his practice. Presumably, he would not favor spiritually-oriented psychotherapies wherein functions and roles of psychotherapy and spiritual direction are combined, insisting that they be separated. While he believes that psychotherapists must be sensitive to the spiritual domain in their work, he contends it "is inappropriate to make spirituality the primary agenda of a psychotherapeutic consultation" (May, 1992, p. 202). Accordingly, only when the psychotherapist is "a gifted spiritual director--and if a clear discernment has been made with the person as to the rightness of the relationship" and only on a temporary basis and would he sanction a helper performing both roles.

May supports this position with the following reasons. First, he insists that it is "an unwise economy of time and emphasis" (May, 1992, p. 207) noting that clients want to use their session time to deal with their problems and difficulties, leaving little if any time for spiritual direction functions. "When you're trying to be spiritual director at the same time, you have to make sure you allow enough time to deal with how prayer is going, what kind of subtle movements and invitations might be happening, the nuances of discernment. Too often these spiritual guidance questions are ignored completely or left for the last few minutes of the hour" (May, 1992, p. 207).

Second, he believes that it is difficult for both client and helper to shift back and forth between the more analytic process of psychotherapy and the very reflective stance and pace of spiritual direction. He notes "you and the client somehow have to shift your attitudes way from problem-solving toward more prayerful openness, and that is not always easy (May, 1992, p. 207).

While the value of the positive position is its advocacy of the spiritual dimension in psychotherapy, the value of the negative position is its recognition of the logistical concerns associated with a non-nuanced approach to spiritually-sensitive psychotherapy. The "negotiated perspective" provides a way of bridging these two perspectives recognizing and respecting the subtle and not so subtle differences between spiritual direction and psychotherapy sensitive to the spiritual dimension. In negotiated perspective, the same helper provides both spiritual direction and psychotherapy functions but in a planned, negotiated manner. This perspective recognizes and accommodates for the problems and challenges--previously noted by Gerald May--facing the helper who combines both functions.

Here is how the functions and roles might be negotiated. Assuming that a client in weekly psychotherapy wants and needs to focus on spiritual issues, treatment can be planned so that one session a month focus specifically on spiritual issues while the other three sessions of the month focus on therapy. While similar issues may be discussed in both types of sessions, the intent and emphasis would be clear and defined. Since spiritual direction sessions in the Christian tradition are typically scheduled monthly, this negotiated perspective provides a proper and effective format for facilitating the process of combining both functions and roles. In my own professional experience, this may be the most appropriate format for practicing Christian spiritually-oriented psychotherapy.

STRATEGIES FOR INTEGRATING THE SPIRITUAL DIRECTION FUNCTIONS

The message so far has been that while spiritual direction and psychotherapy share some commonalities they are far from being interchangeable. This poses a number of challenges for those desiring to integrate the two. Nevertheless, integrating the spiritual direction functions into psychotherapy does not have to be an all-or-nothing proposition: either integrate all eight functions or don't incorporate any functions. At least two integration strategies are possible.

Strategy 1. In this strategy all of the eight functions, or most of them, are incorporated into the psychotherapy process. Psychotherapists who are likely to utilize this strategy share a number of commonalities that facilitate the application of this integration strategy in their practices. Typically, these psychotherapists have had the experience of participating in their own spiritual direction with an experienced director. They also experience a strong desire and feel called to offer spiritual direction. Moreover, they have clients who want spiritual direction provided in the context of their psychotherapy. Finally, they have been able to arrange scheduling and fees so that the spiritual direction functions can be sequenced with the psychotherapy functions. For example, for clients who are seen weekly, these therapists may schedule one session a month devoted principally to spiritual direction concerns, while the other sessions that month are devoted primarily to psychotherapeutic concerns.

Strategy 2. In this strategy only two or three of the spiritual direction functions are incorporated into psychotherapy. There are probably a larger number of psychotherapists who are interested in providing psychotherapy that is sensitive to spiritual issues but who cannot easily incorporate more than a couple of these spiritual direction functions in their therapy. The two spiritual direction functions that are most easily incorporated are spiritual assessment and advisement.

Spiritual assessment is the essential for a therapist who endeavors to offer spiritually-sensitive psychotherapy. Even a brief spiritual assessment can reveal the client's current spiritual practices, image of God, and past and present religious and spiritual concerns. Based on this assessment the therapist, in collaboration with the client, can choose to focus therapeutically on a issue that has spiritual meaning, refer the client to a minister or other spiritual guide, or consider a spiritual practice.

One aspect of the advisement involves spiritual practices for which the therapist might prescribe, monitor, and offer advice and feedback. Spiritual practices are focused activities that foster spiritual qualities, which can result in a balanced and disciplined lifestyle. Whether utilized as an intervention within a treatment session or prescribed as an intersession activity, spiritual practices can be a powerful adjunctive to the treatment process. Commonly used spiritual practices include meditation, fasting, reading sacred writings, healing prayer, forgiveness, moral instruction, and service. Spiritually-oriented interventions include spiritually-focused cognitive restructuring and guided imagery strategies. Several other such spiritual practices and interventions have been described (Miller, 1999; Richard & Bergin, 1997; Sperry, 2001).

CONCLUDING COMMENT

A fascinating trend has been noted in the past few years: Clients are seeking to deal with spiritual issues and concerns--which have traditionally been associated with spiritual direction-in the context of psychotherapy. This phenomenon has increased interest in the spiritually-oriented psychotherapies and, not surprisingly, psychotherapists with an interest in the spiritual dimension are considering how they might respond to this need. Four questions were posed at the outset of this article. The first and second questions concerned the appropriateness of psychotherapy dealing with spiritual concern when spiritual direction has traditionally focused on these concerns. It was concluded that spiritual concerns can be appropriately dealt with in psychotherapy, and, because of both access issues and competency, spiritually-sensitive psychotherapists will increasingly be called upon to provide such services. While it is unlikely that spiritually-oriented psychotherapy will or should replace spiritual direction, sp iritually-oriented psychotherapies is a useful and necessary adjunct to it. The third and fourth questions concerned the receptivity and effectiveness of psychotherapy in dealing with spiritual concerns. It was proposed that psychotherapy increases its receptivity by incorporating some or all of the functions of spiritual direction within psychotherapy practice. Some ways of incorporating these functions were suggested as well as certain cautions to consider. There is reason to believe that this trend will not be shortlived. Needless to say, the impact this trend has on the practice of psychotherapy is rather heartening to professionals with a faith perspective. For many it portends to offer a bright and challenging way of extending the scope of their practice in line with their beliefs and values.

Table 1

Functions of Spiritual Direction and Psychotherapy

FUNCTIONS OF SPIRITUAL DIRECTION  FUNCTIONS OF PSYCHOTHERAPY

Spiritual assessment              Initial psychological evaluation

Differentiating spiritual         Differential diagnosis
experience from psychopathology

Transformation                    Symptom reduction, increasing
                                  functioning, personality or
                                  character change

Triadic relationship              Dyadic therapeutic alliance

Advisement                        Therapeutic interventions, i.e.,
                                  interpretation, cognitive
                                  restructuring, etc.

Discernment                       (Mutual collaboration)

Spiritual resistance              Psychological resistance

Transference and                  Transference and
counter-transference              counter-transference

(1.) The ethical consideration of training and experience to extend the scope of one's practice is an important matter that will not be addressed here due to space limitation.

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AUTHOR

SPERRY, LEN. Address: Campus Box 460, Barry University, 11300 N.E. Second Avenue, Miami Shores, FL 33161. Title: Clinical Professor of Psychiatry, Medical College of Wisconsin, and Professor of Health Administration and Psychology, Barry University. Degrees: BA, St. Mary's University; MA, Loyola University; DMin, Barry University; PhD, Northwestern University. Specialty: Integrating spirituality and psychotherapy; personality disorders.

Correspondence regarding this article should be addressed to Len Sperry, PhD, Campus Box 460, Berry University, 11300 NE Second Avenue, Miami Shares, FL 33161.