Abstract
This paper surveys the current understanding of spiritually integrated psychotherapy (SIP) and connects the historical role of religious training to better understand how SIP is developing as a psychotherapy modality in Ontario, Canada. The paper clarifies how SIP is defined and proposes three levels of practice: spiritually conscious therapy, spiritually informed therapy, and spiritually integrated therapy. As evidence-based and practiced-based literature expands, more consensus is needed in how SIP terminology is used.
Introduction
Spiritually integrated psychotherapy (SIP) is developing in Ontario as a recognized therapeutic modality. The influence of three separate but connected entities – the College of Registered Psychotherapist of Ontario (CRPO), five theological colleges (Knox College, Emmanuel College, Martin Luther University College, Tyndale University, and Saint Paul University), and the Canadian Association for Spiritual Care/Association canadienne de soins spirituels (CASC/ACSS) – and their unique contribution to an emerging understanding of SIP as a therapeutic modality will be described.
SIP is an umbrella term used to denote the act of welcoming the spiritual into the psychological and the psychological into the spiritual. There is a range of definitions of SIP from psychologists and psychospiritual practitioners and a variety of ways that SIP is practiced. A lack of uniformity in the definition and practice of SIP is not surprising for a developing field of study. However, the significant influence from psychologically trained practitioners (in research and publishing) has meant that SIP may be developing without referring to the substantial contributions from the fields of theology and spiritual care. Practitioners with theological training have a long history of integrating spirituality into psychotherapy. How we think about SIP informs how we educate and train psychotherapy and spiritual care practitioners and shapes the kinds of questions asked in research. The authors of this paper are researchers, practitioners, and educators engaged in the training of graduate-level students in the practice of SIP offered through theological college degrees recognized by the CRPO for entry to practice competency as registered psychotherapists. Students specialize in spiritual integration from a particular faith tradition (Christian, Muslim, Jewish, Buddhist) but are also prepared in multifaith and secular understanding and practice.
Evidence that integrating a client's religious faith or spirituality (R/S) into psychotherapy is beneficial to the client is mounting (Currier et al., 2021; Pargament et al., 2005; Rosmarin et al., 2015). Simultaneously, there is growing awareness within the psychotherapeutic community of the need to care for the whole person, including consideration of a client's culture, beliefs, values, spiritual history, spiritual practices, and experiences (Plante, 2008; Sim et al., 2022). This is good news for clients. But how does a therapist ethically and knowledgeably integrate a client's faith into the therapeutic context? What is spiritually intregrated psychotherapy and what does it look like when practiced? This paper has three aims: (1) to explore how SIP is currently defined and described in the literature; (2) to discuss the ancient connection between spirituality and care of the soul and the importance of recognizing this history as SIP continues to develop. We note the impact that the historic split between the secular and religious domains had upon psychotherapy – namely the diminution of the spiritual in therapy; (3) to present where re-integration (of secular and spiritual) is occuring among practitioners, theological colleges, and psychotherapy regulating bodies to foster an understanding of SIP as a modality.
The term SIP was popularized by Ken Pargament in his ground-breaking book Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred (2007). As a psychologist and researcher, Pargament maintains that a client's spirituality is interwoven with the psychological fabric of being such that the two are indivisible (Pargament et al., 2005). Definitions of spirituality abound but a helpful description by Davis et al. (2023) as cited in Currier et al. (2024) describes spirituality ‘as peoples’ search for meaning and connection with whatever they perceive as sacred, … or aspects of life viewed as a manifestation of the divine (e.g., close human relationships)’ (p. 2). Spirituality includes a sense of belonging, meaning making, comfort and hope, and may be understood as connected to something more or that which is transcendent. Spirituality differs from religion, which is, as per the working definition used by the authors, a set of organized beliefs and practices that foster understanding of a faith tradition shared by adherents. A client's spirituality can be a source of strength and therefore part of the solution in resolving life challenges, but spirituality can also be a source of conflict or distress such that it contributes to struggles in everyday living (Pargament & Exline, 2022).
The American Psychological Association (APA) published the APA Handbook of Psychology, Religion, and Spirituality (Pargament et al., 2013) which may have helped to increase practitioners’ openness to addressing spiritual or religious concerns in psychotherapy. By endorsing the assessment for spiritual struggle or spiritual distress, the APA implicitly validated research on how spirituality and religion can impact therapeutic outcomes and promote mental health. There is now a firm body of research that connects spiritual health with mental health (Koenig et al., 2001; Rosmarin et al., 2015) and a growing number of studies affirming that people want the opportunity to integrate the spiritual aspects of themselves into their healing process in order to reduce psychological distress and improve spiritual well-being (Captari et al., 2018; Pargament & Exline, 2022; Rosmarin et al., 2021). The burgeoning interest in how to implement the spiritual side of therapy is addressed in the APA's recently published Handbook of Spiritually Integrated Psychotherapies (Richards et al., 2023). Practitioners have permission to listen for spiritual connotations, sensitively probe the way people construct meaning (including their sense of the transcendent), and include interventions and practices that support a client's spiritual and psychological wellness. The welcoming of spirituality into therapy has helped the profession consider the whole person in treatment and has led to the development of SIP as both a practice and a modality.
Methodology
This paper employs a hermeneutical methodology (O’Connor, 2005; Rediger, 1986). This method is often used in theology and spiritual care. Hermeneutical research is different from empirical research in that it is a critical examination of relevant texts to consider answers to a research question. A current example of hermeneutical research is Erin Snider et al. (2022) in their description and analysis of clinical wisdom. They gathered 40 texts on this topic and noted eight themes that describe clinical wisdom from these 40 texts. In our hermeneutical research on SIP, we used several search engines and databases (PsychInfo, Alta Religion database and PubMed) to discover articles that refer to and/or define SIP. To address our first aim of understanding how SIP is presented in the literature, we asked the question, ‘What is spiritually integrated psychotherapy’? We identified fifty relevant articles to compare definitions and conceptualizations and critically analyze. This analysis is presented below. One finding is that most articles using the title of SIP were published within the last fifteen years, although the spiritual practice of the cure of the soul (psychotherapy) is an ancient tradition in many religions.
Hermeneutical research focuses on the interpretation and understanding of the written text and for this paper it includes peer-reviewed papers, published books, and publicly accessible material from websites of spiritual and psychological professional organizations and institutions. It is a methodological approach of engagement with data gathered from existing written material, and then interpreted through processes of critical analysis and reflection. The hermeneutical circle views a single concept, in this case – SIP, first on its own and then in a spiraling fashion outward to encompass the broader context and narrative in which the concept exists. We, therefore, considered how the terminology of SIP is used in the literature and then set the concept of SIP within a historical religious context and the current Ontario, Canada context. We asked the questions, ‘Historically, how has spirituality and care of the soul been taught?’, ‘How did they separate?’ and currently, ‘What is the impact of the CRPO's decision to include SIP as one of the recognized psychotherapy modalities, as evidence of the coming back together of secular and religious domains in psychotherapy’? We present how SIP is emerging in Ontario in conjunction with the establishment of the CRPO and the offering of graduate theological degrees in SIP that train psychotherapists and spiritual care practitioners. Teaching offered at theological colleges, clinical practicums offered by CASC/ACSS (to be cited as CASC for the duration of the paper) and the regulation of the act of psychotherapy by the CRPO was examined in relation to how each are influencing one another in accepting SIP as a modality. In Ontario, the CRPO has included SIP as a psychotherapy modality in its own right as compared to limiting spirituality as merely an augmentation to traditional psychotherapy modalities. The hermeneutical researcher engages in an iterative and circular interpretive analysis by moving back and forth between the data for deeper understanding and consideration of the data within the wider circumstance (Paterson & Higgs, 2015). Therefore, the results and discussion sections have been combined as part of the non-linear and interpretive aspect of hermeneutical research.
Results and Discussion
How is Spiritually Integrated Psychotherapy Defined in the Literature?
The terminology in peer-reviewed literature that references SIP is creatively varied with nomenclature pointing towards both conceptualization and practice. SIP is referred to as ‘spiritually sensitive approaches’ (Koenig, 2023), ‘religious and spiritual adaptions of psychotherapy’ and ‘R/S-tailored psychotherapy’ (Captari et al., 2018), ‘spiritual psychotherapy’ (Rosmarin et al., 2021; Schuttenberg et al., 2022), ‘spiritually informed therapy’ (Plante, 2024); ‘pastoral counselling’ (Snodgrass, 2019), and ‘psycho-spiritual therapy’ (Alton, 2020; Lasair, 2020; O’Connor & Meakes, 2021). Often these terms are used interchangeably with SIP. The variety of nomenclature may indicate that some forms of spiritual therapeutic research may not be equivalent. Distinctions on the level or degree and kind of spiritual integration are needed.
The research literature provides numerous one-sentence definitions of SIP that are broad and overlook the complexity of what SIP looks like in practice. A helpful but brief example is Richards and Barkham's (2022) description of SIP as guiding practitioners to inquire and address religious and spiritual concerns within traditional psychotherapeutic modalities. The description is echoed by Johnson et al. (2022): ‘Spiritually integrated psychotherapies (SIPs) are defined as any therapy involving the strategic integration into therapy of attention to spiritual content or perspectives’. Currier et al. (2024) note that SIPs foster a deeper exploration of ‘clients’ spiritual and/or religious concerns when clinically relevant, and use culturally responsive language and possible interventions that respect clients’ R/S’ (p.2).
SIPs cover the spectrum from religion specific approaches (such as R-CBT, Religiously Integrated Cognitive Behavior Therapy), to therapies based on defined psychological modalities (such as psychodynamic, family systems, or CBT) which then incorporate spiritual exploration. The purpose of SIP is ‘to affect positive change’ as described by Rosmarin et al. (2021, p. 507) in support of psychologically based clinical outcomes. A continuing education module offered through the Association of Clinical Pastoral Education (ACPE) notes that SIP is an evidence-based practice where the therapist's spiritual perspective (including having no faith) is also important (Snodgrass, 2019). The ACPE (n.d.) Training Program states that SIP ‘draws upon diverse spiritual traditions and psychological research to provide practical, usable resources to help therapists integrate spirituality into their work. It teaches therapists how to elicit and make therapeutic use of their clients’ spiritual perspectives and how to make ethically appropriate use of their own spiritual perspectives.’ The ACPE program focuses on the practical side of implementing this modality as compared to the theoretical. This educational training promotes mastering spiritual assessment and spiritual interventions to be included within a therapeutic modality, much like including cultural considerations to address the intersectionality of the client. Each of the above descriptions of SIP share a common understanding of SIP as starting with a psychological theory for assessment and treatment but assisted by spiritual and religious exploration (and perhaps intervention). Limiting SIP as simply ‘adding in’ spirituality to psychological-based therapy hides the depth and intentionality that practicing this form of therapy encompasses, and it ignores the long history of spiritual integration in therapy in the promotion of spiritual and clinical outcomes.
When Does Spiritual Integration Happen in Practice?
Incorporating spiritual assessment and/or interventions in therapy is important, but researchers are identifying that how spiritual integration actually happens can be confusing for practitioners (Captari et al., 2018; Schuttenberg et al., 2022; Sim et al., 2022; Viftrup et al., 2013). Captari et al. (2018) described four points in the treatment plan where religious or spiritual integration can occur: conceptually assessing for spiritual strength or struggle, incorporating spiritually oriented treatment goals, including spiritual interventions, and within the interpersonal process. Conceptually, as practitioners assess for psychological distress or functional impairment, the client's religious or spiritual framework, spiritual history, and how spirituality or religion might contribute to strength and/or distress are also explored. Particular attention is given to how the presenting issue is being impacted by the client's spiritual beliefs and practices. Pargament and Exline's book Working with Spiritual Struggles in Psychotherapy (2022) walks the practitioner through an understanding of where spiritual struggles come from and how to address them such that struggles can become a source of strength and not be viewed as part of the client's pathology.
The second point in treatment for addressing spiritual concerns is in the treatment goals. A client who is religiously oriented may cite spiritual well-being or a deeper connection with the transcendent as an outcome of therapy and, therefore, an exploration of the client's spiritual framework would be valued as a part of the treatment plan. Rosmarin et al. (2021) found a surprising result in their inpatient research using the SPIRIT (spiritual psychotherapy for inpatient, residential, and intensive treatment) protocol with acute psychiatric patients. Almost forty percent of the subjects in the study had no religious affiliation ‘and most of these patients reported benefits from SPIRIT. Religiously affiliated and unaffiliated patients were equally likely to identify spiritual distress during SPIRIT participation’ (p. 512). Although a practitioner might assume that a client who is not religious would not want or benefit from spiritual integration, the results of this study point to the importance of considering spirituality in treatment goals.
Modifying traditional psychotherapeutic interventions by adding a spiritual component is the third point in care where spiritual integration is possible. In addition, therapy can be supplemented with religious/spiritual interventions or spiritual practices such as prayer, use of sacred texts, or religious rituals in keeping with the client's faith perspective. Some therapies may be tailored to a specific faith tradition, such as Wani and Singh's (2019) investigation of Islamic psycho-spiritual therapy with cannabis users. In this study the Islamic practices of Repentance (Tawbah), Prayer (Namaz), Mindful Meditation (Dhikr) and Recitation of Quran were incorporated with psychological interventions. Captari et al. (2018) acknowledged a fourth means of R/S accommodation as occurring within the interpersonal dynamic between client and therapist such that the relationship could be experienced by the client as a healing relationship. The latter description of the therapeutic benefit and sacredness of the relationship is akin to the idea of ‘way of being’ (Fife et al., 2014).
Many descriptions of SIP start with the assumption that the psychological aspects of the person and the psychological theoretical framework of the therapist are primary focal points that can be augmented by exploring the spiritual. From this vantage point, SIP views people as psychological beings who have a spiritual side, and by addressing R/S values, experiences, and struggles, psychological and relational problems may be resolved, as noted in the APA Handbook of Psychology, Religion, and Spirituality (Pargament et al., 2013). Although SIP may ‘also foster spiritual change and growth, SIP accomplishes this as a by-product that accompanies psychological change’ (Pargament et al., 2013, p. 227). This description of the primacy of the psychological is echoed in the newly released APA publication Handbook of Spiritually Integrated Psychotherapies (Richards et al., 2023). Positive psychological outcomes take precedence, and positive spiritual outcomes, if they occur, do so occur within psychological change.
Saunders et al. (2010; as cited in Abernathy et al., 2021) suggested that integrating the spiritual into psychotherapy functions on a continuum with minimal integration at one end and a far greater level of integration at the other. At the beginning of the continuum is ‘spiritually conscious care’ where the practitioner respects the intersectionality of R/S in the client's life and is open to exploring R/S concerns as relative to the presenting problem, openness and respect being the operant variables. Moving along the continuum is ‘spiritually integrated care’ where the practitioner adheres to a traditional modality of therapy but also actively ‘includes R/S beliefs, practices, and relationship in treatment for the purpose of promoting psychological outcomes’ (p. 273). Saunders et al. (2010) described the far end of the continuum as ‘spiritually directive care’ where the practitioner assesses the faith background of the client, creates treatment outcomes that are both psychological and spiritual (emphasizing transformation in spiritual or religious practices), and accomplishes this by intentionally incorporating the client's spirituality into the therapeutic interventions. Concerns were cited about potential role confusion for those trained in psychology to be venturing into the domain of the theological. The continuum is helpful in noting that spiritual integration can be a little or a lot but confusion arises in that all three levels are referred to in the research literature as spiritually integrated care and differentiation is not identified.
The authors of this paper suggest that the nomenclature of spiritually integrative therapy be reserved for all robust forms of SIP that include spiritual and psychological assessment, treatment and outcomes. Therefore, where practitioners are sensitive to listening for the spiritual, spiritually conscious therapy is employed. Where therapists are attuned to assessing or integrating spirituality into a traditional therapeutic modality, in support of psychological outcomes, spiritually informed therapy is practiced. And where spirituality is at the core of the therapy, giving equal weight to both the spiritual and the psychological in terms of assessment, goals, interventions, relationships, and outcomes, there spiritually integrated therapy is involved.
Let us consider three clinical practice examples of rigorous spiritual integration to illustrate SIP according to the author's description above. First, a practitioner adapts the psychological interventions of a recognized modality to include spiritual components and outcomes (i.e., religious cognitive behavioral therapy [RCBT]; Koenig et al., 2015). Second, a spiritually based clinical protocol is integrated as a treatment modality. There are numerous excellent examples of spiritually integrated protocols, including the ‘structured chaplain’ intervention for addressing moral injury in U.S. veterans (Ames et al., 2021), the ‘building spiritual strength’ intervention for PTSD care (Harris et al., 2018), and the SPIRIT clinical protocol for group psychotherapy (Rosmarin et al., 2021; Schuttenberg et al., 2022). The SPIRIT clinical guideline is part of a cognitive behavioral approach to therapy. A third example of robust spiritually integrative care is the practice of psychospiritual therapy. Psychospiritual integrative models combine the spiritual and psychological in therapy starting from the premise that we are spiritual beings and employ psychotherapeutic modalities as a spiritual practice with the treatment goal of spiritual wholeness (Alton, 2020). An example is spiritually integrated cognitive processing therapy (SICPT), which ‘is a spiritually/religiously integrated treatment for MI in the setting of PTSD…[which] uses the patient's spiritual/religious beliefs to process traumatic events and dysfunctional cognitions’ (Koenig & Al Zaben, 2021, p. 3003). In the therapy manual, there are religion-specific appendices to assist therapists in offering religiously sensitive care. Further examples include the relational spirituality model (REM) (Sandage et al., 2020) and the diamond approach (Alton, 2020). What these examples of clinical practices share is the prioritization of spiritual integration at all four points in therapy (treatment goals, assessments, interventions, and therapeutic relationships).
Koenig (2023) added a further consideration to the idea of spiritually integrated care by noting the importance of tailoring interventions to the uniqueness of the client's faith rather than offering a generic ‘spiritual’ approach. In advocating for person-centered mindfulness, Koenig proposed that therapists employing mindfulness or meditative techniques in therapy do not assume a solely Buddhist approach to mindfulness but recognize that other world faith traditions each have their own rich traditions in meditation. Koenig advocated for practitioners to integrate interventions that are relevant to the client's faith tradition by utilizing Christian meditation for Christians, Muslim meditation for Muslims, and so forth. To do so requires knowledge of other world faith traditions and next level training in spiritual integration. This kind of care is not just adding the spiritual into the therapeutic conversation but rather is an intentional act to integrate relevant practices that align with the client's spiritual and religious worldview.
An Ancient Connection Between Spirituality and Cure of the Soul
The roots of SIP go back to the ancient Greek philosopher Socrates. Psychotherapy is a Greek derivative meaning cure and/or care of the soul. This term was developed by Socrates who maintained that doctors cure the body and philosophers cure the soul (Overholser, 2010; O’Connor et al., 2014; O’Connor & Meakes, 2014).
In the West, Christian theologians and other religious leaders in the early centuries of Christianity adopted Socrates’ term and saw pastoral care as the cure of the soul (Clebsch & Jaekle, 1983). These Christian pastors and theologians also utilized the various Greek understandings of the soul and saw the work of Jesus Christ as caring and curing the soul such that persons could turn to religious leaders for guidance, comfort, and assistance when experiencing psychological or emotional/spiritual difficulties. In their historical description of pastoral care, Clebsch and Jaekle (1983) saw four functions of this cure of the soul: healing, guiding, sustaining, and reconciling. These four functions dominate the writings of Church theologians down through the centuries when discussing pastoral care. Kolbet (2010) examined the writings of Augustine of Hippo from the fourth century around pastoral care and noted that Augustine focused on the cure of the soul from a neo-Platonic background. He believed that the words of the Christian pastoral caregiver were mingled with the Word of God in facilitating the care of the soul of a distressed person. McNeill (1951) wrote History of the Cure of the Soul, which analyzed Christianity and other religions and examined how the cure of the soul was lived out within each of them. O’Connor et al.'s Psychotherapy: Cure of the Soul (2014) included a series of chapters by a variety of thinkers and theologians from Judaism, Islam, Christianity, Buddhism, Paganism, and Canadian Indigenous spirituality. Each author described how psychotherapy is lived out in connection within their own faith group. Spirituality is at the basis of each notion and practice. While SIP is a new term, it has a long history of thought and practice in many of the world's religions.
One challenge between spiritual care and psychotherapy is rooted in the conflict between religion and science that arose in the West in the sixteenth century. Prior to the Renaissance, religion and science had a strong connection. Medical physicians in the Middle Ages were given their certificate to practice through a theological school and many priests were also medical physicians (Koenig et al., 2001). With the controversy between the Church and Galileo in the sixteenth century, there developed a conflict between religion and science. The Roman Catholic Church, based on its understanding of Scripture, believed the universe was earth-centric, that is, that the sun revolved around the earth. Galileo, based on his scientific study, showed that the earth revolved around the sun (Barbour, 1997). Ian Barbour (1997) has said that from this conflict (and subsequent conflicts such as the theory of evolution in the nineteenth century) a relationship of conflict and separation developed around religion and science where each tried to prove the other wrong. The neophyte discipline of psychology endeavored to identify with the science of behavior and stripped itself of an association with religion and spirituality (Plante, 2024). Barbour has noted that three other relationships between religion and science developed over time: a second, of peaceful co-existence, where each dealt with separate spheres, religion with the spiritual and immaterial and science with the physical; and a third, where religion and science began to deal with some issues that were on the boundary between them, like hope and love and the connection of the spirit and soul with the body. A fourth relationship emerged where religion, spirituality, and science were integrated. An example of integration can be found in SIP where spiritual care and psychotherapy are practiced together.
Spirituality and psychotherapy in the 19th and 20th centuries experienced their own unique rift or conflict. In the nineteenth century, Sigmund Freud stripped psychotherapy of its religious and spiritual elements. He did not believe in God and thought that religion was often harmful to the psychic health of humans (Stokes, 1985). For Freud, putting spirituality together with psychotherapy was an oxymoron. Religion was at best separate from psychotherapy. Many psychotherapists, psychologists, and psychiatrists in the twentieth century, including B. F. Skinner and Albert Ellis, were educated in this Freudian bias and were both dismissive and demonstratively ‘negative about anything to do with religion’ (Plante, 2024, (p. 2). The majority of psychotherapeutic modalities and those trained in them have been from a strictly secular perspective. It is not surprising that many in the helping professions continue to work from a secular perspective. Those who separate spiritual care or spirituality from psychotherapy are dealing with Barbour’s (1997) second relationship—one with strong boundaries between the two that usually offers a peaceful co-existence but at times a conflictual one.
Barbour's (1997) third and fourth relationship – of an emerging connection between religion and science that moves toward a more thorough integration of the secular and the sacred is exemplified by the establishment of the APA Division 36, the Society for the Psychology of Religion and Spirituality, which formed in 1976. This example of the re-integration of the secular and the religious continues with the Division 36 peer reviewed journal entitled Psychology of Religion and Spirituality. In 1946, a group of Christian mental health professionals began the Christian Association for Psychological Studies (CAPS) to foster scholarly discussion and research in the intergration of spirituality and psychotherapy. There is a growing abundance of spiritually and psychologically integrated professional associations with peer reviewed journals.
The act of integrating spirituality and psychotherapy has a long tradition in the pastoral counselling movement, faith-based counselling, and spiritual care/pastoral care practice. It is beyond the scope of this paper to describe the synergy of what Clinebell (1992) describes as the convergence of four phenomena – the emergence of the Clinical Pastoral Education (CPE) movement, the contributions from the social sciences to understanding human behavior, the expansion of psychotherapies to include cognitive, humanistic, existential and systems orientations, and the cultural zeitgeist and passion for psychology and psychotherapy after World War II – that created fertile soil for the development of the pastoral counselling movement. Clerics, as part of the ancient caring and helping tradition woven into their calling, often found themselves beyond their scope of practice and noted the need for training in both the theological as well as the psychological arts to attend to the spiritual or emotional needs of others.
In the mid-twenties, the Presbyterian minister and hospital chaplain Reverend Anton Boisen, one of the founders of the pastoral education movement (later called CPE and pastoral counselling education [PCE]), together with Richard Cabot, Richard Dicks, and others, pioneered a unique training program for faith leaders to work with psychiatric hospital patients (Bard, 2016). The program combined clinical bedside experience with reflective practice to bring together the theological and the psychological. CPE programs are in many countries around the world. The pastoral counselling stream separated in 1964 to form the American Association of Pastoral Counsellors (AAPC) and recently re-merged with CPE training under the ACPE (Snodgrass, 2019). Practitioners in the CPE movement as well as the pastoral counselling movement have dual training, first in theology/spirituality/world faiths and then also in the psychological art and science. Hence, their frame of reference for understanding personhood begins with the spiritual. Persons are seen as spiritual beings having a human experience rather than as human beings who happen to have a spiritual side. Faith, spirituality, and theological understandings are the foundation of this therapeutic modality that integrates psychotherapy as an equal partner.
The emerging integration, or re-integration, of the spiritual and psychological, is exhibited in the published clinical competencies of organizations whose members offer SIP. The Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) identifies competencies for addressing spiritual and religious issues in therapy that work in tandem with codes of ethics and standards of professional practice. For example, the counselor is to explore their own attitudes, beliefs, and values about R/S [ASERVIC, n.d]. Similar spiritual clinical competencies are identified by the Canadian Association of Spiritual Care where the PCE and CPE streams share the same clinical competencies. Examples of spiritual competencies from CASC include 4.2.5 Assesses spiritual distress, spiritual pain, suffering, grief and loss; 4.3.3 Utilizes reflection from religious/theological/spiritual/cultural perspectives for the purpose of meaning-making with clients; and 4.5.7 Educates and advocates for the value of spirituality to health and wellbeing [CASC, n.d.a]. The clinical competencies of organizations such as ASERVIC and CASC complement those of professional regulatory bodies for the promotion of integrating spirituality and psychotherapy.
How SIP is Emerging in the Ontario, Canada Context: the Three Influences of CRPO, Master Level Theological Training, and CASC
In Ontario, Canada, a robust conceptualization of SIP is emerging. The convergence of three forces in Ontario is producing a juggernaut that is changing the psychotherapeutic landscape for practitioners who offer SIP. The first dynamic force is the College of Registered Psychotherapists of Ontario (CRPO) which oversees provincial legislation that regulates the controlled act of psychotherapy. Therefore, anyone practicing therapy in Ontario must be registered with the College. CRPO's inclusion of SIP as a therapeutic modality in its list of recognized modalities (equal to other traditional modalities) in tandem with CRPO's recognition of practitioners with theological and psychological training (including CPE as a recognized training program in SIP) has significantly altered the psychotherapeutic landscape by giving credibility to SIP as a modality. The second influence is the emergence of master level degrees specializing in SIP offered at theological colleges (mainly in Ontario but dialogue is emerging across the country among theological colleges). Seminaries have a long history of training professionals for congregational ministry and for pastoral counselling. What is new is the offering of degrees in psychotherapy that are also recognized by Canadian psychotherapy regulating (or licensing) bodies. Seminaries outside of Ontario, such as St. Stephen's in Alberta, are in dialogue with newly established or establihsing regulatory bodies. The third influential force is the adoption of SIP by CPE programs in Ontario as the theoretical basis of their supervised practicums (where students learn through action and reflection to integrate the spiritual and the psychological in clinical contexts). The CPE programs are all offered as courses (or practicums) through the theological colleges and the CPE units are certified by the CASC. All three entities—the CRPO, theological seminaries, and the CASC—are responding to one another's conceptualization of SIP. A delicate tapestry is being woven so that to describe one of these influences necessitates the intertwined description and influence of the other.
Influence One: the College of Registered Psychotherapists of Ontario (CRPO)
Government regulation of psychotherapy is relatively recent in Canada. The purpose is to ensure competent and ethical practice and thereby protect the public (College of Registered Psychotherapists of Ontario [CRPO, n.d.a]. It takes years to establish the policies and procedures, staffing and by-laws of a regulatory college before it is open for member registration. In 2007, the Ontario legislature passed the Psychotherapy Act, and thereafter established a Transitional Council to oversee the regulations of the college, including the entry to practice competencies and education expectations for practitioners offering psychotherapy. The official opening of the College of Registered Psychotherapists of Ontario (CRPO) occurred on April 1, 2015, as one of numerous healthcare colleges under the Ontario Ministry of Health. The arrival of a government-regulated professional college meant that all persons in helping professions needed to ascertain if their work fell within the description of the act of psychotherapy. The ‘Draft Policy on Activities that Do Not Constitute the Controlled Act of Psychotherapy’ (CRPO, n.d.b) states:
In order for a Registered Psychotherapist (RP) to engage in the controlled act of psychotherapy:
there must be a psychotherapeutic relationship between client and RP; the RP must be providing treatment intended to help individuals improve mental health and wellbeing; the RP must be using a technique that is captured by the categories of prescribed therapies; the client must be suffering from a serious disorder of thought, cognition, mood, emotional regulation, perception or memory; and the client's disorder may seriously impair the individual's judgement, insight, behavior, communication or social functioning. (p. 1)
Although emotionally supportive care, crisis care, and spiritual direction are all exempt from the controlled act of psychotherapy, numerous pastoral counselors, psychospiritual therapists, and spiritual care practitioners affiliated with the CASC recognized that their work did fall within the CRPO's psychotherapy scope of practice and that they did engage in the act of psychotherapy. Vanderstelt (2014) observed hospital-based spiritual care professionals in their practice with patients and noted that 64% of the interactions were psychotherapeutic. Though the sample size was small, this research study affirmed that persons trained in CPE and in PCE both engaged in the act of psychotherapy with patients regardless of the length of the session. The integration of Pargament's book Spiritually Integrated Psychotherapy (2007) into CPE units and his presence at several Ontario conferences has had a significant impact as CASC-affiliated practitioners sought to understand the distinctiveness of their practice. Pargament was a keynote speaker at a CASC conference in Cambridge, Ontario, at the invitation of Sr. Colleen Lashmar of the Waterloo Lutheran Seminary (who had a leadership role in the field) in 2012 and presented on the use of SIP. In the spring of 2013, the Society for Pastoral Counselling Research (SPCR) hosted a conference entitled ‘Spirituality and Psychotherapy: A Cure of the Soul’ with Pargament and Joyce Rowlands, then the registrar for CRPO, as keynote speakers. These conferences were attended by several hundred spiritual care and mental health professionals and helped to clarify how the care of the soul is also connected to assessment for spiritual distress and treatment of spiritual issues alongside psychological ones. Different language systems and identities were merging. At the same time, the conferences exposed the leadership of the CRPO to a large group of professionals who were articulating their practice of SIP.
Understanding SIP as a modality was occurring simultaneously for CRPO's leadership and practitioners. The CRPO recognized the education and training of spiritual care professionals and the importance of admitting them into the newly formed regulated college. Spiritual care practitioners and psychospiritual therapists embraced the language of assessment and treatment in psychotherapy and took on the professional identification of psychotherapist. Therefore, CRPO was helping spiritually oriented professionals to claim their history in the care of the soul, to recognize the importance of their theological and pastoral (and therapeutic) education, and to connect how their CPE training helped them to integrate the spiritual and the psychological. Between 2014 and 2019 (before the controlled act came into effect on December 31, 2019 (CRPO, n.d.b), many Ontario-based pastoral counsellors, psychospiritual therapists, and spiritual care practitioners applied to be grandfathered into the CRPO and thereby become registered psychotherapists (RPs). These practitioners recognized that although their first professional degree may have been theological (a Master of Divinity or a Master of Pastoral Studies), they also had significant training and experience in pastoral care and psychotherapy thereby meeting the educational and practice qualifications (Mills, 2022). At present, more than half of the associate and certified CASC members in Ontario are also registered psychotherapists. The CRPO has acknowledged the psychotherapy education embedded within some theological degrees and integrated into the practice of CPE in Canada and has accepted their supervised practice hours as well as didactics as training in SIP.
The CRPO identified five major treatment modalities (cognitive and behavioral therapies, experiential and humanistic therapies, psychodynamic therapies, somatic therapies, and systemic and collaborative therapies) with the expectation that practitioners are competent to work from one or more modalities. The first list of modalities was presented to members with an invitation for feedback. In 2018, the revised list of modalities was presented with the important inclusion of SIP as a modality within the experiential and humanistic therapy category. SIP is recognized by the CRPO as a specific modality alongside Gestalt, emotion focused therapy, and play therapy (CRPO, n.d.c.) It is significant that CRPO accepted SIP as a modality and recognized that practitioners using SIP employed a set of techniques particular to this modality that included spiritual assessment and spiritual interventions.
Influence Two: Graduate Degrees in SIP at Theological Colleges
The graduate degree curriculum of programs that are training students for entry to practice in psychotherapy is being shaped by the practice competencies of psychotherapy regulatory colleges. This is especially evident in Ontario. CRPO does not accredit education programs, but it does encourage psychotherapy training programs to be vetted through a rigorous third-party evaluation, for the purpose of recognition by the CRPO (and listing on their website). Recognized education programs have curriculum that prepares students to develop the CRPO entry to practice competencies such that students meet minimum education requirements (CRPO, n.d.d). Five Ontario theological colleges, most being affiliated and federated with publicly supported universities (Trick, 2015), transitioned degrees in pastoral care and/or theology and counselling to include sufficient psychotherapeutic content to meet entry to practice competencies and become recognized training programs in psychotherapy by the CRPO. Five theological colleges are among the 29 programs currently recognized, but they were part of the first 15 approved programs by October 2018, representing at the time 27% of the approved education programs. Therefore, by October 2018, one in four recognized training programs for psychotherapy in Ontario was training in SIP. These colleges include Knox College and Emmanuel College (both at the Toronto School of Theology affiliated with the University of Toronto), Martin Luther University College (at Laurier University in Waterloo), Saint Paul University (at the University of Ottawa), and Tyndale University (an independent Christian college in Toronto). CRPO recognized these degrees as adequately preparing students for practice, and theological colleges were offering psychotherapy-oriented degrees because the curriculum aligned with the core identification and mission of spiritual care and counselling training historically located within theological training.
Theological colleges have a long history of offering a substantial array of training courses in psychotherapy and counselling. To obtain the CRPO program recognition, these five theological colleges added new courses where necessary and augmented content in existing courses to ensure entry to practice competencies. This was accomplished while retaining the degree requirements for a solid foundation in faith knowledge. Faith foundation courses include knowledge of sacred text, history of faith, theological/spiritual thinking, and ethical perspectives. The spiritual care and therapy courses offer an integration of psychotherapy and theology/spirituality to help students think about who they are as practitioners, how a particular modality speaks to the spiritual aspects of a person or issue, and what it means to offer SIP.
The programs at Ontario theological colleges offering degrees in SIP are evolving in their understanding of the SIP modality. There is a reciprocal relationship between the professors/practitioners/researchers who teach and the students. Those who are teaching are informing and shaping while also being transformed in their thinking by the students who are writing from their own distinct spiritual or religious perspectives on how they bring together the spiritual and the psychological in their practice. What is consistent is the conceptualization that we are spiritual beings for whom spiritual well-being is essential. The theological and sacred text courses provide a foundational understanding for the integration of the psychological with the spiritual as the starting point for understanding persons and issues in living. The wisdom from psychology augments and informs spiritual understandings. Students complete five or more faith foundation courses, 10 or more psychotherapy courses that emphasize SIP, and one or more clinical practicums. Today there is a growing contingent of practitioners in Ontario who identify as spiritually integrated psychotherapists, with many calling themselves psychospiritual therapists.
A highly significant contribution of the SIP degrees to SIP modality development is that all but one of the five Ontario theological colleges recognized by CRPO intentionally recruit and welcome persons from all faith traditions, including those persons who are ‘spiritual but not religious.’ Although each theological college degree has separate multi-faith requirements such as a course in multi-faith leadership and care, one college offers specialization in Buddhist, Muslim or Christian faith foundation courses, another theological college offers a Jewish or Christian faith foundation courses. All of the colleges respect the diversity of faith of clients and are explicitly training students in robust skills in multi-faith spiritual assessment and spiritual interventions. These students are emerging from their degree programs with a strong spiritual and psychological foundation and with the language to describe what it means to be a spiritually integrated therapist.
Influence Three: Impact on CASC CPE Training and Nomenclature
The largest spiritual practitioner professional organization in Canada is the CASC (n.d.b). Nowhere has the impact of CRPO been felt more in CASC than in the offering of CPE and PCE in Ontario. These supervised training programs require 400 h of training and include direct contact care, individual and group supervision, and didactics in spiritual care and psychotherapy. Once the CPRO was established, the Ontario Ministry of Colleges and Universities required that all vocational training in psychotherapy be offered through accredited university/college or private colleges with students paying tuition directly to those institutions. In 2018, CASC was sent a letter to cease and desist from offering any CPE and PCE vocational training since it incorporated psychotherapy (with many members claiming training in CPE as part of their psychotherapeutic training). This impacted approximately 20 CPE and PCE centers in Ontario. CASC members had to choose between having program autonomy for CPE and the integration of spirituality and psychotherapy knowledge and skills as the basis of CPE. The choice was clear—CPE had SIP at its core and, therefore, all CPE programs in Ontario needed to comply with the Ministry of Colleges and Universities expectation for vocational training in psychotherapy. The result was that all CPE programs became affiliated with a theological college offering programs recognized by CRPO, and CPE was offered as a master level course, with student registration fees paid to the theological college. Supervisor educators became adjunct faculty of the theological college, and CPE and PCE programs became accountable to the theological college (as well as to CASC).
The shift in the locus control and authority is profound and has taken ten years of negotiation and adjustment. Supervisor educators of CPE and PCE are expected by the theological college to be RPs with supervisory qualifications, and to practice from a particular modality. The majority identify SIP as the preferred choice. It is challenging for Supervisor-Educators from other Canadian provinces (or from the United States) to be hired for supervisory positions in Ontario unless they have psychotherapy training and are willing to become RP's. Supervisor educators must provide a curriculum that integrates psychotherapy into their training according to a syllabus, yet their primary role is in the spiritual and professional formation of the student. Student CPE complaints go to the university and the theological college that may withdraw the CPE supervisor educator's adjunct faculty status if difficulties arise, thereby cutting off a CPE or a PCE program from being able to be offered. The CPE fees go to the theological college which reimburses a portion of the fees back to the CPE supervisor educators. These changes protect students and raise the standard of supervision and accountability. It has not been a comfortable shift for the CPE and PCE supervisor educators, but most acknowledge the benefit of recognition by the CRPO of their work in spiritually integrated practice for the supervision of direct contact client hours.
Nomenclature of SIP professionals has been evolving in Canada in response to a growing number of CASC members who are from diverse faith traditions, as a result of a cultural shift away from the ‘pastoral’ terminology to ‘spiritual,’ and because of the perception by CASC members that their work falls within the scope of practice of registered psychotherapists. In 2010, CASC members voted to change their organizational name from the Canadian Association of Pastoral Practice and Education (CAPPE) to the Canadian Association of Spiritual Care (CASC) to demonstrate inclusiveness (Clark & Wilson, 2016). In 2019, CASC revised the entry to practice competencies for certified professionals and merged the two streams of spiritual care and therapist into a single set of competencies, noting the similarity of the work in spiritually integrated practice. In 2022, CASC membership voted to change the name of their CPE programs from CPE to clinical psychospiritual education (CPE) and to change PCE to psychospiritual therapy education (PTE) (CASC, n.d.). A change was made in all professional certification titles to replace the word ‘pastoral’ with ‘psychospiritual.’ A synergy in Canada for identifying SIP as a member in its own right at the table of psychotherapies has been created by several factors: the joining of psychotherapy regulatory colleges by persons who identify as practicing spiritually integrated psychotherapists; the CRPO's recognition of such practitioners and their training (both at designated seminaries and through CPE); the change in nomenclature by CASC to reference psychospiritual therapy and psychospiritual education; and the acceptance of SIP as a modality by CPRO, the theological colleges in Ontario, and CASC.
Conclusions
It is imperative that as SIP evolves as a modality, its definition becomes more robust. The plethora of definitions and the breadth of understanding of its utility can be confusing to would-be practitioners wanting to implement wholistic treatment. Clarification is needed in terms of the kind of spiritual integration and the degree of spiritual integration. To reduce confusion, we propose the following distinctions: ‘spiritually conscious care’ as support offered by practitioners who are open and curious but have no training in SIP; ‘spiritually informed care’ as therapy offered by practitioners who have an introduction to spiritual assessment and intervention but work from a psychological modality; and that the designation of ‘spiritually integrated psychotherapy’ be used by practitioners who have some level of training in both spirituality/theology and psychotherapy and who actively seek the mutual benefit of both spiritual and psychological outcomes. Dynamic models of SIP are emerging such as the Relational Spiritual Modality (RSM). A recent research study utilizing REM found evidence that clients want to engage their spiritual/religious and or existential concerns in therapy and viewed such integration as relevant to the kind of concerns that brought them into therapy (Sandage et al., 2022). To study SIP adequately, researchers need better descriptions of the type and level of integration being studied.
In Ontario, SIP or SIP, often called psychospiritual therapy, is evolving with distinct criteria for practitioners and expectations for education and practice. Practitioners of SIP, who are members of CASC, have a well-developed spiritual and/or theological competency, so that while they tend to be grounded in a particular faith tradition, they have at least a working knowledge of other faiths and the important practices associated with them. They have training in personal religious bias to help ensure that they do not impose their own faith understandings upon others (CASC, n.d.b). Spiritual competency is acquired through graduate level theological training and/or CPE and PCE units of integrated practice. There is some overlap with professional education for spiritual direction. Practitioners of SIP are trained to explore the spiritual, existential, religious, and theological dimensions of the client and to knowledgeably address the client's spiritual concerns. For the psychospiritual therapist or spiritual care practitioner, it is not that spirituality must be addressed explicitly but that there be an assumption that spiritual concerns or struggles, spiritual strengths, and spiritual worldviews are in operation at all times and can therefore impact the client's psychological and physical well-being.
The authors of this paper suggest that the following description of SIP be considered:
SIP is a theologically/spiritually informed psychotherapy (practitioners have both theological/spiritual training as well as psychological training [theoretical or assimilative]), such that secular psychotherapies are adapted to make room for the client's spiritual or religious beliefs. SIP understands all persons as having a spiritual dimension (in addition to the physical, mental, and social), which is central to healthy well-being. SIP assesses, through active listening, the client's sense of the spiritual as a source of strength, a source of struggle, or a source of distress (Including inquiry about faith, beliefs, spiritual experiences, and spiritual practices as places of strength, struggle, or distress). SIP collaborates with the client to address the spiritual dimension in therapy and may include spiritually informed interventions as appropriate and according to the belief system or spiritual understanding of the client (not the therapist). SIP attends to the ethically appropriate use of the therapist's own spiritual/religious tradition. SIP welcomes spiritual wisdom as well as psychological research to inform best practices.
Spiritually integrated practitioners welcome the use of psychotherapy modalities as a partner in the treatment of wholistic care. Treating the whole person, including how the client makes meaning of their distress, and assessing the life practices, spiritual and otherwise, that support and give the client strength, would be considered essential in therapy and not merely an optional addition to psychotherapy. In this manner, SIP as a psychospiritual therapy is distinct from the proposed definition of SIP set forth in the Handbook of Spiritually Integrated Psychotherapies (Richards et al., 2023) which welcomes the spiritual but maintains psychological theory as the foundation.
The five theological colleges in Ontario offering graduate-level training in SIP are at the leading edge of what it means to have dual training in both spirituality and psychotherapy. Their graduates are emerging as SIP practitioners and there is a need for practice-based research to understand the experience of implementing SIP from both the therapist and the client perspective. Richards and Barkham (2022) have noted that research ‘is needed about how practitioners incorporate spirituality into their clinical practices’ and ‘how psychotherapists implement spiritually integrative approaches in routine practice’ (p. 304). In Ontario, due to the significant number of spiritual care practitioners in healthcare settings who are also registered psychotherapists, there is need for practice-based research on how this group is utilizing SIP at the bedside with patients. Captari et al. (2022) echoed the need for research into ‘the conditions and mechanisms that make SIP's effective- or ineffective- in the complexities of routine practice with diverse patient populations’ (p. 308). There is an additional, important, educative role for theological colleges. Mandelkow et al. (2022) referred to the ‘religiosity gap’ where psychologists tend to be significantly less religious than the general population. Sim et al. (2022) highlighted the dilemma for psychotherapists who, if they are not trained to assess spiritual distress, may ignore or avoid therapeutic conversations that involve spiritual concerns. Increasing spiritual knowledge competency is a necessary first step followed by increasing spiritual care competency for practitioners wanting to engage in SIP. Theological colleges have expertise and a deep and rich history in SIP and would do well to share that expertise by offering continuing education in spiritual knowledge and competency for mental health practitioners who want to engage in SIP.
The addition of SIP to CRPO's list of recognized therapeutic modalities has helped to delineate the practice of SIP as a recognized modality of therapy. By recognizing student training programs for degrees—following a rigorous vetting process—specializing in SIP and the admittance of practitioners who have training in both theology and psychotherapy, the CRPO has helped to validate SIP as a modality in itself. SIP student practitioners being educated in Ontario's CRPO-recognized seminaries are learning to do both psychological and spiritual assessment, to develop treatment plans that acknowledge spiritual and psychological outcomes, and to employ interventions that integrate spirituality and traditional psychotherapy. Their spiritual and theological faith understandings are developed over five or more courses in a religious tradition and one or more courses addressing multi-faith understandings for therapy. Each psychotherapy course provides an opportunity to integrate faith understandings with psychological theory and practice. The goal is to have psychospiritual practitioners who think about the problem and its origins as well as the solution from both a spiritual as well as a psychological perspective. This form of SIP that is developing in Ontario does not only add a spiritual component to a secular modality but also acknowledges a spiritual foundation and builds the psychological upon it.
Recommendations
The authors offer the following four recommendations:
Categories of SIP be developed to clarify the kind and degree of spiritual integration in therapy. A definition of SIP be developed with sufficient complexity to describe the breadth of practice while balancing spiritual and psychological assessment, intervention and outcomes. Practice-based research be conducted to understand the experience of implementing SIP for therapists and spiritual care providers trained through CPE. Theological colleges help fill the knowledge gap by offering continuing education for practitioners who want to develop spiritual competency to provide spiritually conscious and spiritually informed therapy.
Footnotes
Acknowledgements
Thank you to Father Edward Wagner for reading the paper.
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.
