Client Perspectives About Religion and Spirituality in Group Counseling

Abstract

The main purpose of this study was to examine client-rated appropriateness and preferences regarding the discussion of religious and spiritual concerns in group counseling. Participants were 164 group clients at nine university counseling centers nationwide. Clients volunteered to complete an online questionnaire about their experiences and opinions regarding religion and spirituality in group counseling. The majority of clients indicated that religious concerns are an appropriate topic for group counseling and reported a preference to discuss religious and spiritual concerns with their groups. Regression analyses examined predictors of client-rated (a) appropriateness of discussing religious concerns in group, (b) appropriateness of group leaders using religious or spiritual interventions, and (c) preferences for discussing religious and spiritual issues in group. The most consistent predictors of these ratings were client spirituality, client religious commitment, degree of spiritual struggles, and the frequency with which religion had already been discussed in the clients’ specific groups.

Keywords

group counseling group therapy religion spirituality

Over the past two decades, research on the religious and spiritual dimensions of counseling has grown considerably (Post & Wade, 2009). However, the vast majority of that research has focused on including religion or spirituality (R/S) in individual counseling (e.g., Aten & Leach, 2009; Pargament, 2007). The limited amount of work that addresses R/S in group counseling focuses primarily on groups with a specific religious or spiritual theme (e.g., Gear, Krumrei, & Pargament, 2009; Genia, 1990). This leaves a gap of knowledge about how R/S might be included in general counseling groups (i.e., counseling groups that have a process and/or psychoeducational focus that include various clients who may or may not share religious beliefs, experiences, or worldviews). The inclusion of R/S in general group counseling is almost entirely uncharted (cf. Cornish & Wade, 2010; Cornish, Wade, & Post, 2012; Post, Wade, & Cornish, 2013); this is especially true from the group client perspective. Finally, religious and spiritual themes and concerns may be important for clients at university counseling centers, given the relevance R/S has developmentally for many traditionally-aged college students (Fowler, 1981; Parks, 2000).

Definition of Religion and Spirituality

For the purposes of this study, we view the terms religion and spirituality as similar, yet distinct constructs (Hill et al., 2000; Zinnbauer et al., 1997). In line with previous research on R/S in general group counseling (Cornish et al., 2012), we define spirituality as “the feelings, thoughts, experiences, and behaviors that arise from a search for the sacred” and religion as “the feelings, thoughts, experiences, and behaviors that arise from a search for the sacred that receives validation and support from an identifiable group of people” (Hill et al., 2000, p. 66). In other words, religion always takes place within the context of an identifiable community, whereas spirituality may or may not receive validation and support from such a group.

Religion and Spirituality in Counseling

Individual Counseling

The bulk of the research on the inclusion of R/S in counseling has focused on individual counseling either explicitly or implicitly (Pargament, 2013). That scholarship has produced a considerable body of knowledge ranging from perspectives about the appropriateness of specific religious and spiritual interventions (e.g., Rose, Westefeld, & Ansley, 2001; Shafranske & Malony, 1990) to client comfort with and effectiveness of religious and spiritual interventions used in a previous session (Wade, Worthington, & Vogel, 2007), to theories that provide guidelines and recommendations for addressing R/S in individual counseling (e.g., Griffith, 2010; Pargament, 2007). This research suggests that many, but certainly not all, clients and therapists believe that R/S can be effectively included in counseling (Diallo, 2013; Rose et al., 2001).

Group Counseling

Although in some instances, the scholarship on R/S in individual counseling can be applied to group counseling settings, direct application of much of this research may be impossible. The structure of general group counseling alone creates a unique setting that might alter client and counselor perceptions, attitudes, and willingness to discuss religious and spiritual issues (Cornish & Wade, 2010). For example, clients might be much less willing to discuss R/S in a group, even if such topics are important to them. The group setting might make them feel more vulnerable discussing R/S or they might fear disrupting the group cohesion if other members are uncomfortable with R/S.

Research on Religion and Spirituality inGroup Counseling

Several research projects have been conducted to explore the efficacy of religiously- or spiritually- tailored group interventions. For example, in a study of a program to target and alleviate spiritual struggles, Gear et al. (2009) designed and assessed a 9-week experiential, discussion-oriented group program. Following the treatment, students reported fewer spiritual struggles, less distress related to spiritual struggles, and less distress in general. Other researchers have integrated religious or spiritual topics and themes into existing group psychotherapy treatments. One of the best examples of this work was the integration of spiritual principles and beliefs based on the Judeo-Christian tradition into group therapy for eating disorders (Richards, Berrett, Hardman, & Eggett, 2006). Compared with a cognitive-behavioral group and a support group, the spiritually-integrated treatment resulted in better outcomes. Clients in the spiritually-integrated group reported significantly less psychological disturbance and eating disorder symptoms, and greater spiritual well-being. These research projects provide valuable information about the role that R/S might play in a group context, when that group is specifically targeting spiritual struggles or using spiritual themes. However, such research provides little information about the ways that R/S might be incorporated into the kinds of groups that are most frequently offered in university counseling agencies and other psychological treatment facilities, that is, psychotherapy groups attended by a heterogeneous membership seeking assistance with psychological problems.

The lack of research on R/S in general group counseling is problematic for several reasons. First, most clients who attend group counseling will attend a group that is not centered on R/S. In university and college counseling centers (UCCCs), most of the groups conducted are general process groups or counseling groups with a focus on a particular problem, such as eating disorders or trauma (Golden, Corazzini, & Grady, 1993). Second, a large majority of college students (and by extension UCCC clients) have religious or spiritual commitments that are important to them (Astin et al., 2005) and many of those have religious or spiritual concerns (C. V. Johnson & Hayes, 2003) that might be fruitfully addressed in counseling (Genia, 1990).

Third, religion and spirituality are important components of diversity that could be effectively addressed in a group counseling setting. Like other areas of client diversity (e.g., sexual orientation, race/ethnicity), religious and spiritual diversity can lead to polarization, misunderstanding, and oppression if not adequately processed. However, with effective processing, such diversity might lead clients toward greater understanding of differences, greater acceptance of themselves and others, and greater psychological and spiritual healing (Gear et al., 2009). Finally, traditionally aged college students are developmentally primed for addressing issues and concerns related to R/S (Astin et al., 2005; Fowler, 1981).

Regarding research on such groups, we are aware of only one study that assessed the inclusion of R/S in general counseling groups from the client’s perspective. Post et al. (2013) examined client perceptions about religious and spiritual topics and interventions in group counseling. One seemingly contradictory finding that emerged was that although 84% of group clients thought it was appropriate for members to talk about religious concerns in group, a much smaller percentage reported that they wanted to talk about religious (24%) concerns with their specific groups. Open-ended responses indicated that one major reason for this was the fear of disrupting group cohesion. Furthermore, greater spirituality and affiliation with the majority religion (i.e., Christianity) significantly predicted preferences to talk about religious and spiritual concerns (Post et al., 2013).

Understanding client preferences is an important clinical issue (Tompkins, Swift, & Callahan, 2013). Research shows that when therapists attend to client preferences and match those with appropriate interventions, clients are less likely to drop out of treatment and have better outcomes (Swift, Callahan, & Vollmer, 2011). There is some evidence to suggest that when client preferences for religious or spiritual interventions are met, clients report better outcomes in individual (e.g., Wade et al., 2007) and group counseling (e.g., Richards et al., 2006). Furthermore, understanding the factors that might predict a group client’s preferences for the inclusion of religion and spirituality in group would give group leaders a head start in identifying and assessing these preferences.

Although the initial study to assess group client preferences for the inclusion of R/S in group counseling (Post et al., 2013) provided an important starting point for research and practice in this area, it was not without its limitations. Specifically, the sample size was small and clients came from only one university counseling center. Also, the predictors of clients’ ratings were limited to client spirituality, religious affiliation, and group engagement. Although these three variables are important, they are limited in scope; other variables are likely to be important as well. For example, religious commitment might be a worthwhile addition because spirituality is only one dimension of how people experience the transcendent. Religious commitment may provide an added dimension by assessing the degree to which people are committed to the specific beliefs and practices within an identified religious tradition. Such a commitment might reflect a worldview that sees religion as important to all areas of life (Worthington et al., 2003) and therefore encourage greater preferences for including R/S in group counseling.

The degree to which clients are experiencing religious struggles might also be an important predictor (Gear et al., 2009). Such clients may have a greater desire to discuss religious or spiritual issues and see them as more relevant and appropriate compared with clients who are not struggling (C. V. Johnson & Hayes, 2003). Because group members often bond with the leaders before group cohesion builds, the working alliance with the group leader(s) might also be an important predictor (Yalom & Leszcz, 2005). Feeling more bonded to group leaders might lead clients to feel safer discussing religious or spiritual issues in group and, therefore, increase their ratings of appropriateness and preference. Finally, we suspect that based on group norms that might get established, clients are likely to rate the inclusion of R/S as more appropriate in groups that have already included R/S (Yalom, 2005). Having seen how R/S can be addressed in group and realizing that their counselors see this as an important topic may cause clients to rate this as more appropriate and to be more likely to prefer discussions than clients who have not experienced discussions of R/S in their groups.

Current Study

The primary purpose of this study was to examine the attitudes and preferences of group counseling clients regarding the inclusion of R/S in group counseling. We designed the current study as a replication and extension of the study conducted by Post et al. (2013) and to apply the growing knowledge of R/S in counseling to a group setting. We have extended the previous work by sampling from counseling centers from several different regions of the United States, including more clients to increase power to detect smaller effects, and by assessing additional variables that may predict attitudes and preferences. Specifically, we addressed two main research questions as follows:

Research Question 1: How do clients perceive the appropriateness of discussing religious concerns and the inclusion of religious or spiritual interventions in group counseling, and which variables of interest predict those ratings?

Research Question 2: To what degree do group clients prefer to discuss religious or spiritual issues with their specific groups, and which variables of interest predict those ratings?

Method

Participants

The sample consists of 164 group counseling clients from nine UCCCs. Participants were predominantly European American (n = 131, 79.8%) with 12 Blacks/African Americans (7.2%), 10 Asians/Pacific Islanders (6.0%), 6 Latino/as (4.2%), 1 Native American/Native Alaskan (0.5%), and 4 “Other” (2.3%). There were 126 females (76.8%) and 35 males (21.3%) with 3 reporting other (1.9%). The most frequently endorsed religious affiliations were other (n = 31, 18.9%), agnostic (n = 28, 17.1%), Protestant Christianity (n = 28, 17.1%), atheist (n = 26, 15.9%), and Catholicism (n = 19, 11.6%) with 10 endorsing Mormonism (6.1%), 6 Buddhism (3.7%), 4 Judaism (2.4%), 4 Unitarianism/Universalism (2.4%), 3 Hinduism (1.8%), 3 Islam (1.8%), 1 Baha’i (0.6%), and 1 Taoism (0.6%). The average age of the participants was 23.2 years (SD = 5.2, range = 18-49). All participants were undergraduate or graduate students at public universities. The institutions they attended represent various regions of the United States: Virginia (n = 52, 31.8%), Iowa (n = 47, 28.8%), Utah (n = 18, 11.1%), Illinois (n = 14, 8.6%), Delaware (n = 12, 7.4%), Oregon (n = 9, 5.6%), Tennessee (n = 6, 3.7%), and North Dakota (n = 5, 3.0%). The majority of participants reported that they had attended individual counseling sessions in the past (n = 152, 92.7%), and 63 clients (38.4%) reported that they had attended group counseling sessions prior to joining their current group. Participants reported attending an average of 10.6 sessions in their current groups (SD = 9.7, Mode = 8).

Measures

Client bond to group counselor(s)

The Working Alliance Inventory–Short Form–Bond (WAI-S-B; Tracey & Kokotovic, 1989) was used to measure clients’ perceptions of their bond with co-leaders. To limit participant burden, participants only completed the four items assessing bond. Furthermore, the following statement was added to the standard instructions: “Although you may feel differently toward each leader, try to think in terms of your general experience with the counselors as a leadership pair.” Horvath and Greenberg (1986) reported internal consistency estimates ranging from .85 to .88 for each of the three subscales. Both expert agreement and empirical methods have supported the content validity for the WAI (Tracey & Kokotovic, 1989). In the current study, Cronbach’s alpha was .90.

Group climate-engagement

The Group Climate Questionnaire–Short Form (GCQ-S; MacKenzie, 1983) measured client perceptions of group cohesion and participation. The GCQ-S is comprised of 12 items and utilizes a 7-point Likert-type scale that measures level of agreement (1 = not at all and 7 = extensively). The instrument consists of three subscales: engagement, conflict, and avoidance. The GCQ-S has been linked to important process and outcome variables in group counseling (Kivlighan & Goldfine, 1991;MacKenzie, Dies, Coche, Rutan, & Stone, 1987). The engagement scale has shown Cronbach’s alphas ranging from .74 to .94 (J. E. Johnson et al., 2006; Kivlighan & Goldfine, 1991). To limit participant burden and because the emotional element of a positive working atmosphere was of greatest interest, we only used the engagement subscale. In the current study, Cronbach’s alpha for that subscale was .82.

Religious commitment

Participants completed the Religious Commitment Inventory–10 (RCI-10; Worthington et al., 2003), a scale that measures commitment to one’s religion, with higher scores indicating a higher level of commitment to one’s religion. The 10-item scale utilizes a 5-point Likert-type scale ranging from 1 to 5 (1 = not at all true of me and 5 = totally true of me). Worthington et al. (2003) tested the reliability and validity of the RCI-10 on three separate samples (n = 155, 132, and 468) of university students. When tested on adults from the community and therapists, normative data for the RCI-10 were similar to the means and standard deviations for the three university student samples. The RCI-10 appears to have an acceptable internal reliability (Cronbach’s alpha typically .92 or above). Test–retest reliability more than a 3-week period was also found to be adequate (α = .87). The RCI-10 has also demonstrated construct validity as it correlates with other measures of religious commitment, belief, and spirituality (Worthington et al., 2003). In the current study, Cronbach’s alpha was .95.

Spirituality

The Spiritual Transcendence Index (STI; Seidlitz et al., 2002) was used to measure clients’ spirituality. The STI is an eight-item questionnaire. Individuals respond on a 6-point Likert-type scale (1 = strongly disagree and 6 = strongly agree). This measure of spirituality was chosen because it is not only brief, but also includes a subscale that measures spirituality in non-theistic terms (α = .96). In terms of validity, the items were reviewed by a panel of spiritual leaders (e.g., nuns, pastors) as well as randomly selected members of the public. Furthermore, Seidlitz et al. (2002) reported that each item loads onto its respective factor at .86 or higher. Because we surveyed clients who may or may not have had religious or theistic worldviews, we only used the non-theistic subscale of the STI. In the current study, the Cronbach’s alpha for this subscale was .94.

Religious struggle

A seven-item measure developed by Astin, Astin, and Lindholm (2011) was used to measure clients’ religious struggle, which “reflects the extent to which [a college student] feels unsettled about religious matters, feels distant from God, or has questioned her/his religious beliefs” (p. 52). Students respond on a 3-point Likert-type scale (1 = not at all, 2 = to some extent, and 3 = to a great extent). Total scores range from 7 to 21. Astin and colleagues tested the reliability of this measure on a large sample of more than 100,000 first-year students at the start of the Fall 2004 semester (Cronbach’s α = .75) and again on a smaller subset of juniors at the end of the Spring 2007 semester (Cronbach’s α = .77). For the Fall 2004 sample, the total score mean was 11.6 (SD = 2.9). In the current study, Cronbach’s alpha was .78.

Perceived appropriateness of religious discussion in group

The religious concerns subscale of the Counseling Appropriateness Check List (CACL-R; Warman, 1961) was used to survey client beliefs regarding the appropriateness of discussing religious concerns in group counseling. The content validity and reliability of the full instrument have been supported in several studies (e.g., Miles & McDavis, 1982; O’Brien & Johnson, 1976; Wilcove & Sharp, 1971). A later factor analysis identified a fourth factor comprised of seven items, measuring religious concerns (Duckro, Joanning, Nathan, & Beal, 1978). In addition to the standard instructions, we included the following statement: “For each problem, decide how appropriate you think it would be for a person to discuss the problem in group counseling.” In the current study, Cronbach’s alpha was .88.

Preference to discuss religion/spirituality in group counseling

The Client Attitudes toward Spirituality in Therapy (CAST; Rose et al., 2001) was used to survey client preferences regarding discussion of religious and spiritual concerns in group counseling. The original version of the CAST constructed by Rose et al. included six pairs of questions, each with a 5-point Likert-type scale, and one open-ended question. Each pair of questions was identical with one difference: one item addressed religion and the other spirituality (e.g., “To what degree is the most important problem that brought you to counseling related to religion/spirituality?”). Rose and colleagues decided that four pairs of items (Items 1-8) best represented the construct of client preference to discuss religion and spirituality in counseling. This factor showed high internal consistency (α = .96). The measure utilized one set of anchors for the first two item pairs (1 = not at all, 2 = not very important, 3 = uncertain, 4 = somewhat important, and 5 = extremely important) and a different set for the second pair of items (1 = not at all, 2 = not much, 3 = uncertain, 4 = somewhat, and 5 = very much).

As we examined the CAST, we were concerned that the anchors did not strictly follow a graduated scale, instead “uncertain” was the midpoint. Also, the use of two sets of anchors seemed potentially confusing to participants. For the sake of continuity and clarity, we adjusted the scale to eliminate the “uncertain” anchor and used the same set of anchors for all items (1 = not at all, 2 = somewhat, 3 = moderately, 4 = very much, and 5 = extremely). Because we were interested in examining the pattern of predictors and replicating the analyses of Post et al. (2013), we computed a religious and a spiritual subscale. Thus, each subscale was comprised of four items. Cronbach’s alpha for the religious subscale (CAST Religion) was .85, and for the spiritual subscale (CAST Spirituality), it was .83.

Perceived appropriateness of religious and spiritual interventions

Participants rated the appropriateness of 22 interventions that therapists could use when religious and spiritual issues arise in group, using a 6-point Likert-type scale (1 = completely inappropriate and 6 = completely appropriate). Twelve items were developed by Cornish et al. (2012) based on their review of previous studies that have examined the appropriateness of religious and spiritual interventions. These 12 interventions are comprised of four pairs of identical interventions that differ only in their usage of the terms religion/religious and spiritual/spirituality (e.g., “Bringing up religion in group” vs. “Bringing up spirituality in group”), and four religious interventions that do not have a spiritual counterpart. Cornish et al. reported that the 14-item scale had a Cronbach’s alpha of .91.

An additional 10 items have been added to the scale for the current study. These items are five religious/spiritual pairs that represent types of interventions that were recommended by Cornish and Wade (2010) as helpful ways to facilitate therapeutic discussions of religion and spirituality in group counseling. Examples include “facilitating a group activity where group members share their religious/spiritual backgrounds” and “conducting a guided meditation that includes religious imagery, language, and symbols.” For the regression analyses, in the current study, 18 of the 22 items were sorted into two groups: nine religious interventions and nine spiritual interventions. The items that represent religious interventions without a spiritual counterpart were excluded from the analyses. Cronbach’s alpha for Religious Interventions was .84, and for Spiritual Interventions, it was .85.

Demographic information

Participants provided demographic information (i.e., age, sex, ethnicity), current religious/spiritual worldview, number of previous sessions of individual counseling, number of group counseling sessions prior to joining current group, number of sessions with current group, and primary presenting concern. Participants also provided the name of their university and the type of counseling group they were attending. Using a 7-point Likert-type scale, we also asked participants to indicate how often the topic of religion has come up in their group (1 = not at all, 3 = occasionally, 5 = often, and 7 = most or all of the time).

Procedures

Participating centers were solicited through personal communication and a general announcement on a listserv for UCCC group therapists. We formed an initial list of 31 sites to contact by identifying sites (a) where a professional colleague worked, (b) that were known to have a strong group counseling program, or (c) that volunteered in response to our general request on a listserv for UCCC group counselors. We provided more detailed information to those 31 sites. In response, 9 sites agreed to participate in the study. Each site offered a variety of process-oriented, theme-based, and psychoeducational groups. Participants were only recruited from psychotherapeutic groups that targeted psychological symptoms or concerns and included unstructured open-process time. Groups with no process component were excluded from the study. This ensured that the clients surveyed in this study were members of groups in which R/S could emerge spontaneously during discussion. Using this inclusion requirement, we recruited from 50 counseling groups, which contained 339 clients at the time of data collection. The majority of these were process-oriented groups (n = 28). All others were theme-based groups (n = 22). Initially, 302 of the 339 group clients (89.1%) volunteered to participate. After the email invitation, 199 (58.7%) started the survey. Of these, 164 clients completed the survey, giving an overall response rate of 48.4% (164 out of 339).

The study was approved by the Institutional Review Board at the authors’ home institution and each of the participating UCCCs. At eight UCCCs, client data were collected in November 2011, after the group had met for more than five sessions. At one center, data were collected in February 2012, again after most clients had experienced at least five sessions. Group leaders presented the study to their clients at the beginning of two consecutive sessions and interested clients shared their email address with the principal investigator. Clients then received an email invitation (and two reminder emails) directing them to an online survey hosted by Qualtrics.

Participants read the informed consent document on the website before they agreed to complete the online questionnaire. Upon completion of the online survey, participants received debriefing information. Following the debriefing screen, participants were given the option to enter their email, confidentially, in a raffle to win one USD $50 gift card to Amazon.com.

Results

Preliminary Analyses

Data cleaning

First, we examined the data set for missing data. Of those participants who completed the survey, six clients (3.7%) left one or more items blank. In these cases, the mean value was calculated for that measure based on the completed items for that participant and then imputed for the missing item. There was only one case of missing values for more than 70% of a scale. This occurred on the CAST. We used listwise deletion for this one case.

Tests for normality, linearity, and homoskedasticity

The data set was examined to determine whether the regression models met the regression assumptions of normality, linearity, and homoskedasticity (Cohen, Cohen, West, & Aiken, 2003). No substantial departures from linearity or residual homoskedasticity were observed for any of the regression models. However, univariate normality was violated by several variables (i.e., preference to discuss religious concerns, preference to discuss spiritual concerns, religious commitment, client bond to group counselor(s), and group climate). We transformed these variables using logarithmic, square root, and inverse transformations to reduce non-normality. We conducted the analyses with both the transformed and nontransformed variables and found no differences in any of the regression analyses. As a result, we reported the analyses using the nontransformed variables because they are easier to interpret.

Correlations and general descriptives

Correlations and general descriptives of the main study variables are presented in Table 1. The table includes the correlation matrix for the variables used in the regression analyses as well as the means, standard deviations, ranges, and Cronbach’s alphas of the continuous variables.

Table 1.

Intercorrelations, Means, and Standard Deviations for Client Variables.

	Measures	1	2	3	4	5	6	7	8	9	10	11
1.	CACL-R	—
2.	PARSIS-R	.52*	—
3.	PARSIS-S	.52*	.85*	—
4.	CAST-R	.30*	.53*	.41*	—
5.	CAST-S	.28*	.47*	.58*	.76*	—
6.	STI	.07	.35*	.35*	.51*	.56*	—
7.	RCI-10	.11	.42*	.35*	.61*	.57*	.74*	—
8.	Religious struggle	.19*	.14	.20*	.26*	.28*	−.06	.01	—
9.	GCQ-Engage	.14	.15	.11	−.05	−.05	.00	−.03	−.08	—
10.	WAI-Bond	.14	−.12	−.03	−.02	.03	−.07	−.07	−.03	.26*	—
11.	Freq Rel. Discuss	.20*	.31*	.30*	.36*	.34*	.04	.16*	.30*	.00	.00	—
M		28.7	33.3	36.3	7.4	8.9	14.7	20.0	12.3	29.0	23.0	2.2
SD		4.3	8.0	7.9	3.6	3.7	6.1	10.8	3.3	4.5	4.2	1.2

Note. N = 163 to 164. CACL-R = The Counseling Appropriateness Check List−Religious Concerns; PARSIS-R = Perceived Appropriateness of Religious and Spiritual Interventions–Religious Items; PARSIS-S = Perceived Appropriateness of Religious and Spiritual Interventions Measure–Spiritual Items; CAST-R = Client Preferences for Discussing Religion in Therapy (CAST Items 1, 3, 5, 7); CAST-S = Client Preferences for Discussing Spirituality in Therapy (CAST Items 2, 4, 6, 8); STI = Spiritual Transcendence Inventory; RCI = Religious Commitment Inventory–10; GCQ-Engage = Engagement subscale of the Group Climate Questionnaire. WAI-Bond = Bond subscale of the Working Alliance Inventory – Short Form. Freq Rel. Discuss = the frequency with which religion had been discussed in the group previously.

p < .05.

Appropriateness of Clients Discussing Religious Concerns in Group Counseling

Descriptive statistics

The first part of our first research question focused on clients’ beliefs about the appropriateness of group members discussing religious concerns in group counseling. The percentage of participants rating each individual concern as appropriate ranged from a high of 95.8% for “Confused on some moral questions” to a low of 59.2% for “Science conflicting with my religion.”

Regression analyses

We were also interested in what variables would predict client ratings of the appropriateness of discussing religious concerns. Therefore, we conducted a hierarchical regression analysis. (Note. Due to agency concerns about confidentiality, we did not have access to which specific group the clients attended. Therefore, we were unable to do multi-level regressions that would account for the nesting of clients within groups. However, in the study that we are replicating, group had very little effect on any of these specific variables, with intraclass correlations [ICC’s] < .02. Therefore, in both studies linear regression analyses were used.) We entered the predictor variables in two sets. The first set was a replication of regression analyses conducted by Post et al. (2013) and included (a) majority versus minority religious affiliation (for counseling centers in all states but Utah, Protestant and Catholics were coded as the majority = 0, in Utah, Mormons were coded as the majority and all others were coded as the minority = 1), (b) majority versus no religious affiliation, (c) client spirituality, and (d) group engagement. The second set included religious commitment, religious struggles, working alliance with the group leader(s), and the degree to which R/S had been discussed in the group.

In contrast to results from Post et al. (2013), who found an R² = .04 (p = .41), the first set of the regression predicting appropriateness of clients discussing religious concerns was significant, R² = .09, F(4, 158) = 4.01, p = .004 (see Table 2). Specifically, those with a majority religious affiliation were significantly more likely to see religious concerns as appropriate for group counseling than those with a minority religious affiliation (β = −.27, p = .003). The addition of the second step was also significant, ΔR² = .07, F(4, 154) = 3.05, p = .02, with an overall R² = .16, F(8, 154) = 3.64, p = .001. In this model, majority religious affiliation remained a significant predictor (β = −.26, p = .005). In addition, religious struggles also predicted appropriateness of clients discussing religious concerns (β = .19, p = .015), such that those with greater religious struggles were more likely to view discussing religious concerns as appropriate.

Table 2.

Hierarchical Multiple Regression Analyses Predicting Client Ratings of the Appropriateness of Clients Discussing Religious Concerns in Group Counseling.

Predictors	R ²	ΔR²	B	SE B	β
Model 1	.09**	.09**
Maj. vs. Min. religion			−2.50	.81	−.27**
Maj. vs. None			−.23	.99	−.03
Spirituality			.08	.07	.11
Group engagement			.13	.07	.14
Model 2	.16**	.07*
Maj. vs. Min. religion			−2.41	.85	−.26**
Maj. vs. None			−.42	1.02	−.05
Spirituality			.08	.08	.11
Group engagement			.13	.07	.13
Religious commitment			−.05	.44	−.01
Religious struggle			.26	.10	.19*
Working alliance			.08	.08	.08
Freq Rel. Discuss			.38	.28	.11

Note. N = 164. Model 1 represents the replication of regression analyses from Post, Wade, and Cornish (2013). Model 2 represents the extension unique to this study. Maj. vs. Min. religion (vs. None) = dummy coded variables comparing those with majority religious affiliation with minority (and no) religious affiliation. Freq Rel. Discuss = the frequency with which the topic of religion had been discussed in the groups.

p < .05. **p < .01.

Appropriateness of Religious and Spiritual Interventions in Group Counseling

Descriptive statistics

The second part of our first research question focused on clients’ beliefs about the appropriateness of therapists using religious and spiritual interventions in group counseling. Means, standard deviations, and percentages of endorsement of specific interventions are reported in Table 3. Results indicated a wide range of ratings, from 84.2% stating that therapists “bringing up the topic of spirituality” was appropriate to only 10.4% stating that it was appropriate for therapists to lead in-session vocal prayer. We then compared the participant ratings of appropriateness of religious interventions (as a set) with appropriateness of spiritual interventions (as a set) using a paired samples t test. Results indicated that clients see spiritual interventions in general as more appropriate (M = 4.0, SD = 0.9) than religious interventions (M = 3.7, SD = 0.9), t(163) = 9.02, p < .001, d = .33.

Table 3.

Descriptive Statistics for Client Ratings of the Appropriateness of Therapists Using Religious and Spiritual Interventions.

Item		M (SD)	% 4+
1	Bringing up the topic of spirituality.	4.6 (1.2)	84.2
22	Exploring spiritual struggles.	4.5 (1.2)	83.5
2	Bringing up the topic of religion.	4.2 (1.4)	76.2
14	Facilitating a group activity where group members share their spiritual backgrounds.	4.1 (1.3)	72.5
20	Highlighting spirituality as a source of strength.	3.9 (1.4)	65.8
7	Using spiritual language or concepts.	3.8 (1.2)	65.2
13	Facilitating a group activity where group members share their religious backgrounds.	3.9 (1.3)	64.0
3	Asking group members about their spiritual beliefs.	3.9 (1.4)	61.6
21	Exploring religious struggles.	4.3 (1.3)	56.1
19	Highlighting religion as a source of strength.	3.5 (1.5)	55.5
4	Asking group members about their religious beliefs.	3.6 (1.4)	52.5
5	Group counselors self-disclosing own spiritual beliefs.	3.5 (1.5)	51.2
8	Using religious language or concepts.	3.2 (1.3)	45.1
16	Conducting a guided meditation that included spiritual imagery, language, and symbols.	3.1 (1.5)	44.5
6	Group counselors self-disclosing one’s own religious beliefs.	3.3 (1.5)	43.3
10	Having a moment of silence for personal prayer.	2.8 (1.6)	31.7
15	Conducting a guided meditation that included religious imagery, language, and symbols.	2.4 (1.2)	17.6
9	Reading/reciting religious scripture.	2.1 (1.3)	13.9
11	Allowing a group member to lead in-session vocal prayer.	2.0 (1.3)	13.4
17	Ignoring the religious aspect of a concern raised by a client.	2.1 (1.2)	11.0
12	Leading in-session vocal prayer.	1.9 (1.3)	10.4
18	Ignoring the spiritual aspect of a concern raised by a client.	2.0 (1.1)	9.1

Note. N = 162 to 164. 1 = completely inappropriate, 2 = mostly inappropriate, 3 = somewhat inappropriate, 4 = somewhat appropriate, 5 = mostly appropriate, 6 = completely appropriate. Items ranked from most to least appropriate. Item numbers refer to the order they were presented to participants. % 4+ refers to the percentage of participants rating each item as 4, 5, or 6 (indicating the item is perceived as at least somewhat appropriate). Percentages do not add up to 100 on all items due to missing data. Items 17 and 18 were reversed prior to summing the items for the appropriateness of religious and spiritual intervention measures.

Regression analyses

To predict client ratings of appropriateness of religious and spiritual interventions, we used the same predictor variables described previously. We conducted two hierarchical regression analyses, one for religious intervention appropriateness and one for spiritual intervention appropriateness. The first regression analysis, which was significant, R² = .21, F(4, 158) = 10.23, p < .001, revealed that greater client spirituality, β = .36, p < .001, and greater group engagement, β = .16, p = .027, were related to greater appropriateness of counselors using religious interventions (see Table 4). In addition, those with a majority religious affiliation rated religious interventions as more appropriate than those with a minority religious affiliation, β = −.27, p = .001. This is in contrast to Post et al. (2013) who found an R² = .03 (p = .71). The addition of the second step was also significant, ΔR² = .14, F(4, 154) = 8.33, p < .001, with an overall R² = .35, F(8, 154) = 10.23, p < .001. For this model, spirituality (β = .24, p = .014), engagement (β = .23, p = .001), and majority versus minority religious affiliation (β = −.20, p = .015) were still significant predictors. In addition, greater religious commitment (β = .23, p = .017), less working alliance (β = −.19, p = .006), and greater frequency of religious discussions (β = .19, p = .009), also predicted higher ratings of appropriateness.

Table 4.

Hierarchical Multiple Regression Analyses Predicting Client Ratings of the Appropriateness of Therapists Using Religious and Spiritual Interventions.

	Religious Interventions					Spiritual Interventions
	R ²	ΔR²	B	SE B	β	R ²	ΔR²	B	SE B	β
Predictors
Model 1	.21**	.21**				.18**	.18**
Maj. vs. Min. Religion			−4.71	1.42	−.27**			−2.43	1.42	−.14
Maj. vs. None			−.73	1.71	−.04			.98	1.72	.06
Spirituality			.47	.12	.36**			.54	.12	.42**
Group engagement			.28	.13	.16*			.22	.13	.13
Model 2	.35**	.11**				.29**	.11**
Maj. vs. Min. Religion			−3.41	1.38	−.20*			−1.72	1.42	−.10
Maj. vs. None			1.04	1.68	.06			1.79	1.73	.11
Spirituality			.32	.13	.24*			.47	.13	.36**
Group engagement			.40	.12	.23**			.31	.12	.18*
Religious Commit.			1.72	.71	.23*			.83	.73	.11
Religious struggle			.32	.17	.13			.48	.17	.20**
Working alliance			−.37	.13	−.19**			−.18	.14	−.10
Freq Rel. Discuss			1.22	.46	.19**			1.09	.47	.17*

Note. N = 162. Model 1 represents the replication of regression analyses from Post, Wade, and Cornish (2013). Model 2 represents the extension unique to this study. Maj. vs. Min. Religion (vs. None) = dummy coded variables comparing those with majority religious affiliation with minority (and no) religious affiliation. Freq Rel. Discuss = the frequency with which the topic of religion had been discussed in the clients’ groups.

p < .05. **p < .01.

Unlike Post et al. (2013), who found an R² = .02 (p = .58), the first step of the regression predicting appropriateness of spiritual interventions was significant, R² = .18, F(4, 156) = 8.40, p < .001, indicating that greater client spirituality was related to greater ratings of appropriateness, β = .42, p < .001. The second step of the regression was also significant, R² = .29, F(8, 152) = 7.76, p < .001, as was the change from Step 1 to 2, ΔR² = .11, F(4, 152) = 6.03, p < .001. In the second step, greater client spirituality still predicted higher ratings of appropriateness of spiritual interventions (β = .37, p = .001), as did greater group engagement (β = .18, p = .014), greater religious struggle (β = .20, p = .006), and greater frequency of religious discussions in group (β = .17, p = .022).

Client Preference for Discussing Religion and Spirituality in Group Counseling

Descriptive statistics

Our second research question addressed client preferences for discussing religious and spiritual issues in group counseling. In other words, do clients have a desire to specifically address R/S in their actual groups? We analyzed the subscales from the CAST that indicated preferences to discuss both religious and spiritual issues with their group. A paired sample t test indicated that clients were more interested in discussing spiritual concerns (M = 2.2, SD = 0.9) than religious concerns (M = 1.8, SD = 0.9), t(162) = 6.22, p < .001, d = .41. The majority of clients reported at least some preference for discussing religious and spiritual concerns in their groups (52.4% and 74.8%, respectively). However, this indicates a sizable minority who did not want to discuss R/S.

Regression analyses

We used the same predictors and step approach to predict preferences as the previous regression analyses (see Table 5). Similar to Post et al. (2013), who found an R² = .46 (p < .001), the first step of the regression predicting preferences to discuss religious issues was significant (R² = .27, F(4, 158) = 14.60, p < .001), with majority versus minority religious affiliation (β = −.23, p = .004), majority versus no religious affiliation (β = −.23, p = .016), and greater client spirituality (β = .37, p < .001) associated with greater preferences to discuss religious issues. The addition of the second step was also significant, ΔR² = .22, F(4, 154) = 16.71, p < .001. At this step, religious affiliation and spirituality were no longer significant predictors. Instead, greater client religious commitment (β = .42, p < .001), more religious struggles (β = .19, p = .002), and greater frequency of previous discussions of religion (β = .22, p = .001) predicted greater preferences to discuss religion in group.

Table 5.

Hierarchical Multiple Regression Analyses Predicting Client Preferences to Discuss Religious and Spiritual Issues.

	Religious Issues					Spiritual Issues
	R ²	ΔR²	B	SE B	β	R ²	ΔR²	B	SE B	β
Predictors
Model 1	.27**	.27**				.32**	.32**
Maj. vs. Min. Religion			−1.79	.61	−.23**			−.28	.60	−.04
Maj. vs. None			−1.79	.73	−.23*			.23	.72	.03
Spirituality			.22	.05	.37**			.36	.05	.59**
Group engagement			−.04	.05	−.05			−.02	.05	−.02
Model 2	.49**	.22**				.51**	.19**
Maj. vs. Min. Religion			−.71	.55	−.09			.64	.55	.08
Maj. vs. None			−.92	.66	−.12			.96	.66	.12
Spirituality			.07	.05	.12			.23	.05	.39**
Group engagement			−.02	.05	−.03			−.01	.05	−.01
Religious Commit.			1.41	.28	.42**			1.19	.28	.35**
Religious struggle			.21	.07	.19**			.27	.07	.24**
Working alliance			.02	.18	.03			.05	.18	.06
Freq Rel. Discuss			.64	.18	.22**			.51	.18	.17**

p < .05. **p < .01.

The first step of the regression predicting preferences to discuss spiritual issues was significant, R² = .32, F(4, 158) = 18.76, p < .001. Consistent with Post et al. (2013), who found an R² = .55 (p < .001), greater client spirituality was associated with greater preferences to discuss spiritual issues (β = .59, p < .001). However, group engagement was not related to preferences as had been found previously (Post et al., 2013). The addition of the second step was significant, ΔR² = .19, F(4, 154) = 15.08, p < .001, with greater spirituality (β = .39, p < .001), greater religious commitment (β = .35, p < .001), more religious struggles (β = .24, p < .001), and greater frequency of previous discussions of religion (β = .17, p = .005) related to greater preferences to discuss spiritual issues.

Discussion

The purpose of the current study was to explore fundamental questions about client beliefs and preferences regarding religious and spiritual issues and interventions within the context of general counseling groups. This study makes a significant contribution to the field by extending the work of Rose et al. (2001) to the area of group counseling and replicating and extending the work of Post et al. (2013). By exploring client beliefs and preferences, this study informs group counselors as they strive to effectively address R/S in their groups.

Appropriateness of Clients Discussing Religious Concerns

On average, group clients reported that religious concerns are appropriate for discussion in group counseling. This is consistent with the results found by Rose et al. (2001) and Post et al. (2013). It may be that in genuinely caring about one another, group members are willing to support others by discussing any concern relevant to another member, even if it is difficult to relate to the issue. This is supported by open-ended responses from our previous publication in which clients reported an altruistic desire to support others wanting to talk about these issues (Post et al., 2013).

Appropriateness of Religious and Spiritual Interventions

There was a broad range of ratings for the appropriateness of the different religious and spiritual interventions we examined. The most appropriate interventions received agreement from 84.2% of the sample, whereas the least appropriate intervention received an appropriateness rating from only 9.1% of the sample. Again showing a range of ratings, 12 out of 22 interventions were rated as appropriate by over half of the clients. In general, clients rated the more explicitly religious (e.g., leading in-session vocal prayer) and active interventions (e.g., conducting a religiously oriented guided imagery) as less appropriate.

In predicting client ratings of the appropriateness of religious and spiritual interventions, several important findings emerged. First, we found that clients who reported greater spirituality and religious commitment rated religious and spiritual interventions as more appropriate. Those more connected to R/S and those for whom R/S is more salient are likely to see the inclusion of R/S as more appropriate. However, we also found that clients in groups who were more engaged, and who had discussed religion previously, rated religious and spiritual interventions as more appropriate. Greater group engagement might help clients feel that their group has the safety and connection needed to discuss the topics of religion and spirituality, which can be sensitive. Furthermore, having already discussed religion might influence clients to see it as more appropriate through norm setting and modeling. Much of the therapists’ work that occurs early in group counseling is establishing the norms of group interaction and modeling appropriate group behavior (Corey, Corey, & Corey, 2012; Yalom & Leszcz, 2005). Therapists who openly invite discussions of R/S, perhaps especially early on in group (as they do with other sensitive topics such as race, gender, and sexual orientation), may create an environment in which clients see religious and spiritual interventions as more appropriate.

Preferences for Discussing Religious and Spiritual Issues

One noteworthy finding from the present study was that there was a mix of preferences for discussing R/S in group. Group clients were almost equally split in their preferences to discuss R/S, with half expressing no desire and half expressing at least some desire. In addition, about a quarter of clients did not want to discuss spirituality, whereas three quarters had some desire. One of the potential barriers to discussing R/S in group is a fear that it will do more harm than good, offending other group members or disrupting group cohesion (Post et al., 2013). This is a concern that group leaders could address directly in helping clients to see the benefit of talking about important, but sometimes sensitive and controversial, topics. This kind of intervention might allow more clients to freely express their own desires in this area.

This idea was supported by the results from the regressions predicting the preference to discuss religious and spiritual issues. Specifically, greater frequency of discussing R/S in the past was related to greater ratings of preference. Perhaps those discussions showed clients that R/S could be addressed in group and that their co-leaders were open to discussing it. In such a climate, clients are perhaps more likely to prefer such discussions than in group climates that are indirectly dismissive, ambiguous or hostile toward the topic.

Regarding preferences for religious discussions specifically, an important pattern emerged. Consistent with the results found by Post et al. (2013), those from a majority religious affiliation reported greater preference to discuss R/S than those from a minority or no religious affiliation. Although when replicating this finding in the first model, the present study did not show these as unique variables beyond religious commitment and religious struggles. This may be due, in part, to overlap between the religious commitment measure and majority religious affiliation, which shows that Protestant and Catholic Christians tend to score higher on the RCI-10 (Worthington et al., 2003). Thus, it is still unknown to what degree being a member of a minority religious group makes members less likely to prefer discussions of R/S or to what degree this has to do with people being more or less committed to their religion.

Implications for Group Counseling

The results of this study have several implications for group counseling, particularly in UCCCs. First, despite the majority of clients rating religious struggles as an appropriate topic to discuss, many fear that sharing their religious or spiritual concerns will damage the cohesion of the group (Post et al., 2013). Group therapists can mitigate this fear. They might facilitate a discussion regarding group members’ views of the appropriateness of discussing religious concerns when it comes up, or provide encouragement and a strong rationale for discussing “difficult topics” that might include R/S. These interventions could be particularly effective within the context of UCCC groups, which tend to be time-limited, and thus, may not progress to a stage where conflict becomes accepted as a natural part of the group process.

Second, although many UCCC clients may want to discuss religious and spiritual issues with their groups, these discussions often do not occur. Therapists might address any concerns members have during the intake and group orientation process as well as in early sessions when topics of a religious or spiritual nature first appear. When uncertain about addressing these issues, therapists can be reassured that a large majority of clients view the exploration of religious and spiritual struggles as an appropriate topic within the context of group counseling.

Finally, it should be noted that clients with a minority religious affiliation might be more hesitant to address R/S in group and see it as less appropriate. To address this concern without abandoning the topic of R/S, counselors might pay particular attention to the ways that minority religious groups are ignored, dismissed, or blatantly derogated, and address those processes quickly and thoroughly. Counselors can certainly set norms against behaviors that hurt others (e.g., name calling, talking as though one’s worldview is the only right way), but they might also employ process comments, modeling, and empathic questioning to help the group explore religious privilege and its quiet but powerful effects in groups.

Future Research Directions

The future research directions in this area are wide open. In fact, almost any question in this area has no direct research or empirical data to inform an answer. Some important, initial explorations might be done in understanding the practice of including R/S in group counseling. The research need in this area is tremendous. The very basic questions of when, how, for whom, and in what contexts discussions about religious and spiritual issues are appropriate and effective need to be examined. For example, future research could be conducted to test the effectiveness of interventions developed to increase client comfort levels regarding the discussion of religious and spiritual issues. Comfort might be raised in several ways, from pre-group preparation materials to overt counselor interventions in the first few sessions. The relative effectiveness of these interventions on group processes and client outcomes is of practical research interest. However, the ethical and clinical ramifications of such interventions are also of interest (e.g., What impact would focusing on R/S have in a specific group in which other areas of diversity do not receive as much explicit treatment?).

Another research implication is the need for greater depth of understanding of client and counselor perspectives on these issues. Qualitative studies could illuminate some of the more nuanced and complex issues surrounding the inclusion of R/S in general counseling groups, such as the varied reactions clients have to the topic and how those reactions relate to the clients’ histories and presenting concerns. Researchers might explore counselors’ decision making when pursuing a topic related to R/S versus when they avoid it. The rich data from a qualitative approach would certainly help to advance our knowledge in this important area.

Finally, another set of research implications is related to how to train group counselors to ethically and effectively address R/S in group. Initial research in this area might pair well with existing research on addressing diversity or other sensitive topics in group counseling (e.g., DeLucia-Waack & Donigian, 2003). Research might be directed toward testing effective training practices, developing group counseling competencies in this area, and understanding factors that impede and promote effective training and supervision of trainees.

Limitations

The low number of ethnic minorities in the present study’s sample is one limitation. However, the proportion of ethnic minority participants is representative of the university populations from which the sample was drawn. Nonetheless, the results of this study may not be generalizable to UCCCs located on campuses with high proportions of ethnic minorities. Religion and spirituality are often important to many ethnic minority groups (Sue & Sue, 2003); therefore, it is possible that a higher proportion of ethnic minorities in the groups surveyed might have increased the preferences for discussing R/S.

Another potential limitation is the response rate of 48%. Although this is comparable with the response rates from other social science survey research (Baruch & Holtom, 2008), it does not preclude the potential for response bias. It is possible that participants who would have made the survey responses different (e.g., higher or lower rates of interest in R/S in group counseling) systematically did not participate. However, the initial interest in the study and willingness to volunteer, which was 89%, indicates that people were not systematically refusing to participate. Instead, the response rate dropped after they received the online link to the survey. Systematic bias is not as likely under these conditions.

The sole dependence on self-report measures is another limitation. Our self-report method may have been biased by social desirability or a lack of nuanced understanding of the issues being explored. For example, clients may have responded differently based on what they thought “discussions of R/S in group counseling” meant. If some perceived this to mean a debate about the veracity of religion, they may have rated their preferences lower than those who understood it to mean an open discussion about each members’ own experiences. Future research would be improved with measures of social desirability and with methods that allow clients and researchers to engage in deeper dialogue about the topic (e.g., focus groups or interviews).

Conclusion

Understanding client preference about religion and spirituality in group counseling is an important first step toward establishing an empirical base in this area of practice. In general, the results paint a picture of group clients who are open to, and even prefer, to discuss religious and spiritual issues. However, there is much left unknown about the ways that R/S should and should not be incorporated in counseling groups. This study suggests the need for further investigation into the role of religion and spirituality in group counseling, to make counseling groups more effective for clients and meet their needs in a wide range of areas.

Footnotes

Acknowledgements

The authors would like to thank the staff and counselors at the participating counseling centers for their help in conducting this research.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Brian C. Post, PhD, completed his doctoral degree in Counseling Psychology at Iowa State University in 2013. He is now a post-doctoral resident in psychology at the Boynton Health Service, University of Minnesota. His research interests include understanding how to effectively include religion and spirituality in counseling.

Nathaniel G. Wade, PhD, is Associate Professor of Psychology and Director of Training in Counseling Psychology at Iowa State University. He completed his doctoral degree in Counseling Psychology at Virginia Commonwealth University in 2003. His research interests include religion and spirituality in counseling, counseling interventions to promote forgiveness, and the stigma associated with seeking psychological help.

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