Spirituality in Rehabilitation Counselor Education: A Pilot Survey.

Counseling has traditionally focused on four forces: psychodynamics, behaviorism, humanism, and multiculturalism, but spirituality is becoming the fifth force (Sandhu, as cited in Stanard, Sandhu, & Painter, 2000). To speak about spirituality is to speak about an individual's value system and it is evident that a client's values enter into counseling. Concerns about client values, beliefs and attitudes have long been considered a central part of the rehabilitation process (Patterson, 1959; Jenkins, Patterson & Szymanski, 1992; Wright, 1983) and western Christian religious practices are arguably at the core of early rehabilitation philosophy (Kilpatrick & McCullough, 1999; Patterson, 1960; Rubin & Roessler, 1995). Traditionally rehabilitation practice articulates the importance of addressing a client's values, beliefs and attitudes, therefore examining how rehabilitation counseling integrates spirituality as a central theme is important. However, incorporating spirituality into rehabilitation counselor training programs may create conflict for counselor educators and counselors because of differing views of the importance of spirituality and even differing perceptions on the nature of spirituality.

Spirituality and Religion: The Eternal Conundrum

Any professional literature search on the topic of spirituality will bring up hundreds of articles and nearly as many definitions of spirituality. In addition to helping professions such as medicine, occupational therapy, counseling and social work, professional journals from engineering, business, and athletic training fields address the issue of incorporating spirituality into their respective disciplines as well. A common theme found in many articles is the problem of distinguishing spirituality from religion (Stanard et al., 2000). Most authors assert spirituality is usually confused with religion, but Benjamin and Looby (1998) differentiate the two in terms of universality; religion may of may not be universal, but spirituality is universal. They acknowledge spirituality as "alive" both in and out of a religious context.

In order to recognize the value differences between clients and counselors, four types of helping orientations to spiritual and religious natures have been identified: rejectionism, exclusivism, constructivism, and pluralism (Zinnbauer & Pargament, 2000). Rejectionism denies the existence of God or heaven and spiritual supporters. Exclusivism is a belief in the ontological proof of religious or spiritual aspects of existence. Constructivism denies absolute religious or spiritual reality, but believes individuals construct their own reality. Finally, pluralism affirms absolute religious or spiritual reality and allows for a variety of interpretations toward that reality (Zinnbauer & Pargament, 2000). While each of these methods differ slightly in their approach, they all combine spirituality with religion.

Spirituality can be expressed as an internal component of an individual's perception of reality, whereas religion is its external manifestation with practices and rituals shared with like-minded people (Hodge, 2000). Spirituality can be defined as:

   A relationship with a Transcendent Being that fosters a sense of meaning,
   purpose, and mission in life. In turn, this relationship produces salutary
   change, such as an increased sense of altruistic love, which has a
   discernible effect upon one's relationship to creation, self, others, and
   the Most High (p.219).

Religion and spirituality may sometimes be used interchangeably. Occasionally the unique characteristics of each may mesh together creating similarities, however, they are two distinct concepts (Hodge, 2000).

Adams et al., (2000) suggest that common threads exist to weave together the fabric of spirituality. "They include a sense of meaning and purpose in life, connectedness to self, the environment, or a higher power, and a belief in a life force (p.167)." In their argument they note that spirituality is separate from religion, but at the same time somehow intertwined, asserting that spirituality can augment religion and that religion can deepen the impact of spirituality.

One way to differentiate between religion and spirituality is to consider the collective, well defined and dogma-laden structure of religion in comparison to the individualized, more unstructured nature of spirituality. Religion, as least as it is practiced among the three monotheistic religions (Christianity, Judaism, and Islam), is a communal, regulated and ideological act (Ellwood, 1992). Adherents to a religion are expected to commune or collectively worship either in the church, the synagogue of the mosque, typically following a well-defined ritual and praying according to strict dogma. Spirituality is a more individual act, eschewing formal external structures, of formally decreed rituals. However, spirituality is part of most religions and each of the monotheistic religions embraces spiritual elements both for collective worship and individual religious practice. Spirituality, conversely, does not require religious adherence. Thus, it could be argued that to be religious is often to be spiritual, at least in part; however to be spiritual is not necessarily to be religious.

Professional Views on Spirituality

In a Journal of the American Medical Association (JAMA) article, Astin (1998) offers three theories as to why clients choose alternative treatment options, including spiritual options: dissatisfaction, control, and philosophy. Dissatisfaction stems from ineffectiveness of traditional healing techniques, through either cost or adverse effects. Control and autonomy are returned to the client through alternative treatment methods. Finally, these treatments may be more compatible with a client's view of the world, personal beliefs, or philosophy.

In nursing, McSherry (2000) suggests that religion and spirituality are actually polar opposites on the same continuum. The fact that spirituality is so ambiguous and subjective may be one reason it is not addressed within the confines of nursing education. Educators cannot hope to teach a concept that is so universal, personal and broad in a realistic manner, yet nursing students are reporting they do not feel trained to handle the spiritual needs of their patients (McSherry, 2000).

An intriguing question for nursing educators is what is actually creating all of this interest in spirituality, and McSherry (2000) argues that it may never be addressed if the emphasis in nursing continues to be on audits and performance. If spiritual aspects are incorporated into training programs simply to allow those programs to label themselves as holistic, then students and educators may not take spirituality training seriously (McSherry, 2000).

Within the discipline of occupational therapy (OT), spirituality is considered to be an important aspect in the rehabilitation process for clients (Engquist, Short-DeGraff, Gliner, & Oltjenbruns, 1996). Knox (1992) conducted a pilot study survey examining occupational therapists from Colorado, in order to determine their ideas, beliefs and spiritual practices both within their personal lives and work. Even though 98% of the respondents felt that spirituality was an important aspect related to recovery from illness and disability, only a little over a half (54%) supported addressing spiritual issues within their profession. Thirty-seven percent reported that they were unsure what their specific role was in respect to addressing this topic. Several respondents (75%) felt that clients should be referred to another profession to deal with spiritual needs, whereas 33% reported that these issues should be addressed within their profession (Knox, 1992).

For some in the field of occupational therapy, work can bring a sense of purpose and meet one's own spiritual needs (Christiansen, 1997). However, this is not a unique concept. In the 17th century debate arose around the concepts of spirituality, government, and the field of science, and religion. Due to the strong influence of medicine on OT, addressing spirituality became inappropriate (Christiansen, 1997). This may have laid the foundation for current occupational therapists' views to not incorporate spirituality into work situations. Other possible reasons for feeling other professions should deal with the client's spiritual needs may be due to the fact that occupational therapists are confused with their role regarding this issue (Knox, 1992), and the difficult nature of attempting to separate spirituality and religion (Christiansen, 1997).

As with other helping fields, professionals in the field of rehabilitation counseling report that spirituality is an important aspect of the rehabilitation process yet it is not a concept that is being well integrated into the client's treatment process (Kilpatrick & McCullough, 1999). This may be due to the lack of training that rehabilitation professionals are receiving in this area, or because spirituality and religion are sensitive personal topics, not amenable to easy discussion and discourse (Kilpatrick & McCullough, 1999).

In recognition of the importance of spirituality in counseling, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) recently released the 2001 Standards asserting that knowledge and skill regarding spiritual issues relevant to different counseling programs is required of all students in CACREP accredited programs. Religious and spiritual values are mentioned within the social and cultural diversity section of the eight CACREP common core areas in which students ate required to demonstrate knowledge. Program area standards specifically mentioning spirituality include: career counseling, college counseling, community counseling, gerontological counseling, marital, couple, and family counseling, and mental health counseling. The program area standards for school counseling make no mention of spirituality. Each counseling program area standard states that students must be able to demonstrate knowledge and skill which, for the above mentioned programs, consists of "implications of social, cultural, spiritual, diversity and equity issues relevant to ... counseling" (p. 14). CACREP has introduced these Standards, however no specific guidance is given as to how spirituality is seen as relevant to the counseling program, nor is any rationale given explaining methods a counselor can employ to effectively deal with spiritual issues (CACREP, 2000).

Spirituality is a major component of drug and alcohol treatment and many rehabilitation counselor training programs include concentrations or specialties in drug and alcohol treatment (Benshoff, Janikowski, Taricone, & Brenner, 1990). Since treatment notions derived from the disease model dominate drug and alcohol treatment, most drug and alcohol treatment programs embrace and teach the spiritual concepts of Alcoholics Anonymous (Matthews, 1998), but the logic is perplexing ... who is teaching (or taught) the teachers? In treatment, as well as in counselor education programs, it seems to be assumed that counselors know what spirituality is or have somehow "picked it up" in either their academic or home training. No universal standards have been set, so there is no way to know how spirituality concepts are being communicated to clients or if those programs incorporating spirituality are doing so in an effective manner.

Carroll (1999) writes, "The importance of the spirituality to the AA program cannot be overstated" (p. 57). She goes on to quote the AA Big Book that asserts that if an individual is "alcoholic", he or she "... may be suffering from an illness in which only a spiritual experience will conquer" (Alcoholics Anonymous, 1976, p. 44). In part this is simply linear logic. A basic belief of Alcoholics Anonymous is that alcohol has assumed an all-powerful, deified role in the life of the alcoholic. Connectedness to self, others, the environment and simple tasks of daily life are overshadowed by the power of alcohol. Recovery means the individual must develop new life skills, and the entire thrust of the 12 steps is incrementally towards developing a sense of spirituality. For example, the first several steps and many AA writings and sayings urge the newcomer to find inner peace; the process culminates in the 11th and 12th steps which urges the recovering person to use prayer and medication to establish a relationship with a higher power, and to carry this "spiritual" awakening to others. (Benshoff & Janikowski, 1999).

Research Questions and Methodology: What is the Status of Spirituality in Rehabilitation Counselor Training?

This pilot study sought to determine the status of training on spirituality in rehabilitation counselor training programs. Using the Membership Directory of the National Council on Rehabilitation Education as a data base, the directory-identified directors of 76 rehabilitation counselor training programs were sent an 8 item survey inquiring about the status of spirituality training in their programs. The questionnaire included queries about the preparedness of faculty to teach in this area, the importance of spirituality in the role of the rehabilitation counselor, and their familiarity with the CACREP standards. In addition, respondents were asked if their training program offered a drug and alcohol concentration and if that concentration incorporated spirituality issues. Finally, respondents were given the opportunity to provide additional comments. The survey is found in Figure 1.

Figure 1 Spirituality in Rehabilitation Counselor Education Survey

1. Do you currently incorporate training on spirituality in the
curriculum of your rehabilitation counselor training program?
Please indicate one of the following:
              Yes, in a distinct class on spirituality
              Yes, within several different classes
              No, students are sent to another class at this university
              No, we do not do anything at all of a formal nature

How many years have you incorporated training on spirituality in your
rehabilitation counselor training program?

2. Is your faculty prepared to train or provide instruction in areas
relating to spirituality? (Yes or No)

3. Is spirituality an important part of the role of the
rehabilitation counselor? (Yes or No)

4.   Do you have a drug and alcohol concentration, major, or
specialization within your rehabilitation counselor training program?
(Yes or No)

5. Do you incorporate spirituality into your drug and alcohol classes?
(Yes or No)

6. Are you familiar with CACREP standards for inclusion of spirituality
in counselor training programs? (Yes or No)

7. Should spirituality be adopted as a required component of
rehabilitation counselor training programs? (Yes or No)

8. Please feel free to add any comments or questions.

The survey was sent via email to 73 program directors and by regular mail to three directors who did not list an email address. Several emails were returned as undeliverable, and were rerouted with success in all but one instance. The researchers purposely did not include a definition of spirituality in the survey, preferring that the rehabilitation counselor training program directors make their own interpretation. This research was approved by the Human Subjects Committee at Southern Illinois University at Carbondale and by the NCRE Research Committee.

Results

Twenty-eight program directors responded to the survey, usually by return email (25 instances) or posted mail, for a return rate of 37 percent. On at least two occasions program directors forwarded the survey to other faculty members described as being more qualified or more prepared to respond to the questions on the survey. In response to question 1, two (7%) directors indicated their programs offered training in spirituality in a distinct class on the subject, and 11 (39%) respondents reported offering spirituality training in several different classes. Of the 15 (54%) directors who reported they did not incorporate spirituality in the rehabilitation counseling curriculum, 3 (11%) reported they sent students to another class in their university, and 12 (43%) reported they did not do anything of a formal nature. The number of years spirituality training was offered by responding programs ranged from 1 to 18+ years with a mean of 7 years.

Thirteen (46%) respondents indicated their faculty members were prepared to offer instruction in areas relating to spirituality and the same number indicated this was not the case. Two (7%) respondents provided no response.

The majority of respondents (n=18; 64%) agreed that spirituality was an important role of the rehabilitation counselor. Four individuals (24%) indicated that sometimes this was an important role, and the same number of respondents indicated it was not an important role, and two (7%) respondents failed to answer this question.

Thirteen (46%) of the programs that indicated they had a drug and alcohol concentration indicated they offered spirituality training in their drug and alcohol classes, and three respondents indicated they did not. Eleven respondents (39%) indicated non-applicable and there was a single non-response. The discrepancy in the number of responses between this question and the previous question was likely due to the wording of the two questions. Drug and alcohol concentrations, majors of specializations were offered by 14 (50%) programs, and at least 2 (7%) other programs offered a class in substance abuse problems, but not necessarily a concentration, major or specialization.

The majority of respondents (n = 17; 61%) were not familiar with the recently published CACREP Standards on inclusion of spirituality in the counselor training curriculum, however 10 (36%) were familiar with those standards with one (3%) non-respondent. The numbers of individuals (n = 11; 39%) who thought spirituality should be adopted as a required component of rehabilitation counselor training programs exceeded by a narrow majority of one the number of respondents (n = 10; 36%) who did not feel spirituality should be a required component. Six individuals (21%) wrote in what may be considered qualified, ambiguous of equivocal responses.

The opportunity to provide comments in question 8 yielded an array of interesting remarks. Nine (32%) respondents took time to include additional remarks.

Discussion

As described earlier, spirituality has become a potent force in many professional disciplines. With the publication of this special issue on spirituality in rehabilitation and release of the recent CACREP standards, spirituality explicitly stakes out a role in the counseling professions. It is there and interest is growing. Logically, then, it seemed appropriate to perform this pilot study to gather baseline information about the provision of spirituality training in rehabilitation counselor training programs. An in-depth statistical analysis will not be presented, nor is one warranted given the informal nature of the survey. Instead, the data will be interpreted using the already presented descriptive data, interwoven with the rich tapestry of comments from respondents to speculate about the role of spirituality in rehabilitation counseling.

The largest majority of respondents (n =18; 64%) to any question felt that spirituality was an important role of the rehabilitation counselor (Question 3). In addition, 4 (24%) respondents replied with qualified or equivocal answers for a total of 22 (79%) respondents suggesting spirituality is part of the rehabilitation counseling role in at least some fashion. For example, one individual felt that spirituality should be included `sometimes' without further amplification or clarification. Another respondent voiced a long cherished rehabilitation value in commenting: "It is important for the RC to be able to relate to clients as whole persons, including this aspect of their being when appropriate." The diversity of views about spirituality as pan of the role of the rehabilitation counselor was reflected in another comment, "I feel that it is, but not all faculty would agree with me because of their own views on spirituality and related matters (religion, etc.)."

If there is fundamental agreement that spirituality is an important role for rehabilitation counselors, then the question of where training should be provided arises. This is not an uncommon question nor is it a question unique to this discipline. Comments from respondents indicated some faculty members received their training in spirituality through self-study, personal life experience or some other uniquely personal situation. In other situations faculty members evidently participated in formal course work, often in schools of theology or religion.

For most people, spirituality is a distinctly personal activity, rarely outwardly expressed and not easily discussed, and perhaps not easily taught. Several years ago at Southern Illinois University at Carbondale, a section on spirituality and religion in recovery was initiated in a course on substance abuse rehabilitation. Many students then, and since then, have commented this was their first exposure to these issues in any of their counseling classes.

Question 7 asked if spirituality should be adopted as a required component in rehabilitation counselor training programs and the responses were nearly evenly divided with 11 (39%) positive responses and 10 (36%) negative responses, along with 4 (14%) equivocal or ambiguous responses. This question generated many written responses. For example, one individual commented, "I think that it should be dealt with in the context of practicum and internship and also in relation to psycho-social aspects of disability." Another respondent suggested adding a courses to the crowded CORE mandated curriculum would reduce program flexibility and strain already tight faculty resources, and other responses stressed the importance of having a competent faculty and being aware of the situational and pedagogical demands of teaching spirituality. Still others characterized coursework in spirituality as very important. Finally, one respondent suggested a course in spirituality was more in the realm of religious practice than rehabilitation.

A majority of respondents (n=17; 61%) were not familiar with the CACREP Standards, and several respondents noted that CACREP had no influences of control over rehabilitation counseling programs, a valid assertion. However, CACREP and CORE have many parallel regulations, and the promulgation of these standards suggests an overall direction for counseling disciplines in general, and will probably influence rehabilitation counseling in the future. Indeed, one respondent noted the importance of becoming aware of the Standards.

Spirituality is a fundamental part of the recovery process from substance abuse for the vast majority of individuals and treatment programs. Consequently it was not surprising to find that 13 of the 14 respondents from schools with concentrations, majors or specializations in substance abuse reported incorporating spirituality issues in their substance abuse classes. Additionally, 10 of the 13 drug and alcohol programs reported offering training in spirituality as a distinct class (n = 1), or as a part of several different classes (n = 9).

Limitations

This article describes a small pilot study that sought information about the inclusion of spirituality in the rehabilitation counseling curriculum. Because of time limitations, the study was conducted by email in most situations. Just under 40% of the programs responded, and it is impossible to know the reasons for this response rate. Some participants may not have responded because of the email format: they may have been uncomfortable with the technology involved, or they may have been uncomfortable with disclosing information about their programs in a medium in which they might be easily identified. The intentional vagueness of the survey may have caused others to not respond. Indeed, several respondents questioned the importance or validity of investigating spirituality issues in rehabilitation.

Several respondents questioned the inclusion of an item about the CACREP standards in the survey, noting, often pointedly, that CACREP does not accredit rehabilitation programs. However, developments in CACREP and CORE have frequently occurred in parallel of in close chronological proximity. A CACREP issue often becomes a CORE issue or the converse. CACREP has taken the lead here: will CORE follow?

Conclusions

Just as spirituality is often described as ambiguous, so too, is the incorporation of spirituality training in rehabilitation counselor training programs. Issues related to spirituality have a long and prized history in rehabilitation, the earliest textbooks and articles and today's textbooks and articles talk about the importance of spirituality related concepts like values, beliefs, attitudes and a holistic approach. Why then, this ambiguity? Speculatively, spirituality is a difficult construct to define, to understand and to teach. For most people spirituality is a private matter and it is not uncommon to avoid public discussion of displays of private matters. Secondly, rehabilitation counseling, and most human services recently have adopted philosophies and policies and procedures demanding concrete, quantifiable outcomes. The profession, funding sources, and the public want to see results, usually couched in terms of successful placement. In comparison, spirituality is a more nebulous concept, perhaps not fully congruent with more pragmatic demands. Finally, the rehabilitation curriculum is crowded, expanding, and being driven by technological innovation. Adding additional materials, particularly vaguely defined materials, may be daunting for some programs. Several respondents echoed this issue asking for or commenting on the need for preciseness of definition of spirituality.

It was not unexpected to discover a near perfect concordance between the numbers of programs offering "in-house" spirituality training (13 programs; 46%) and the number of programs offering "in-house" drug and alcohol concentrations (11 programs; 39%). Spirituality has a rich history in drug and alcohol treatment and many drug and alcohol accrediting and certifying organizations require training in spiritual dimensions of counseling. Not surprisingly, programs with drug and alcohol concentrations also had the most well-developed and articulated spirituality training, and clearly are leaders in the rehabilitation community in this area.

Despite the ambiguities related to course offerings and faculty preparedness, the clear majority of respondents felt spirituality was an important role of the rehabilitation counselor, although on 4 (14%) occasions with situational caveats added. Consequently, coming to an unambiguous conclusion is difficult. On one hand rehabilitation counselor educators tend to believe that spirituality is an important role of the rehabilitation counselor; on the other hand they are less sure of the faculty's preparedness to teach in this area and are less likely to offer coursework

In the final analysis, spirituality appears to be an important topic in rehabilitation, especially within programs offering drug and alcohol coursework, and rehabilitation educators seem to recognize its importance to practitioners. But, spirituality remains ambiguous within the field of rehabilitation counseling, needing a definition and further clarification. Although some of the rehabilitation counselor training programs surveyed indicated that spirituality had a role in rehabilitation counseling practice, a call for CORE standards seems unwarranted at this time. Since the counseling literature indicates increased counselor awareness and sensitivity to the topic, it seems reasonable that rehabilitation counselor training programs will consider incorporating some aspect of spirituality training within their respective programs on an individual basis. Until a change in CORE standards occurs, rehabilitation counseling students may have to seek out spirituality from alternative sources, and rehabilitation educators may have to weave spirituality into already full course loads. Further research regarding student and faculty knowledge of, and belief in, spirituality as a construct is necessary.

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Rachael L. Green
John J. Benshoff
Jennifer A. Harris-Forbes

Southern Illinois University at Carbondale

John J. Benshoff, Ph.D., Rehabilitation Institute, SIUC, Rehn Hall, Carbondale, IL 62901-4609. Email: [e-mail]