The Religious and Spiritual Beliefs and Practices among Practitioners across Five Helping Professions

E.C.P

Emerging research has indicated that mental and physical healthcare providers' integration of clients' religion and spirituality (RS) in treatment has the potential to positively influence a variety of clinical outcomes (Koenig 2015;Koenig et al. 2012Koenig et al. , 2001)).Such integration of RS not only increases clients' perceived levels of social support and lowers the level of stress experienced, but has the power to equip clients with sources of comfort, hope, and healthy coping skills to navigate their current struggles (Koenig 2004).However, one critical component to the integration of clients' RS is the practitioners' RS-a leading predictor of practitioners' views and behaviors for integrating clients' RS in practice (Oxhandler 2017).
While several definitions exist, religion is "a system of beliefs and practices observed by a community, supported by rituals that acknowledge, worship, communicate with, or approach the Sacred, the Divine, God (in Western cultures) or Ultimate Truth, Reality, or Nirvana (in Eastern cultures)" (Koenig 2008, p. 11).On the other hand, spirituality is understood as "the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationship to the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and formation of community" (Koenig et al. 2001, p. 18).While the two terms are distinct, they both involve the thoughts, behaviors, feelings, and life experiences that surface as a result of one's pursuit of the sacred (Hill et al. 2000).
For this reason, a variety of helping professions are turning their attention toward the role of RS in clients' lives and mental and behavioral health treatment (Carlson et al. 2002;Oxhandler et al. 2015;Shafranske and Cummings 2013;Sheridan 2009).Across ethical guidelines in social work, psychology, marriage and family therapy, counseling, and nursing, practitioners are called to acknowledge this area of clients' culture through the treatment process and to not discriminate based on one's RS (American Association for Marriage, Family Therapy [AAMFT] 2012; American Counseling Association [ACA] 2014; American Nurses Association 2015; American Psychological Association [APA] 2010; National Association of Social Workers [NASW] 2017).
Given that 83% of Americans believe in God and 77% describe religion as somewhat or very important in their lives (Pew Research Center 2015), clients are likely engaging in religious coping-whether positive or negative (Pargament 1997)-within their everyday lives.Therefore, with the significant role RS plays in the United States (US), it is critical that helping professionals be aware of and competent in the complexities related to integrating clients' RS.

Religion/Spirituality in Health and Mental Health Treatment
Not only does emerging research indicate the integration of clients' RS in treatment helps improve outcomes (Koenig et al. 2001(Koenig et al. , 2012)), but a recent literature review indicates that across studies, many clients have a desire to discuss their RS as it relates to treatment, and for the therapist to initiate the conversation (Harris et al. 2016;Oxhandler et al. forthcoming).Thus, it is imperative this area of diversity is acknowledged early in treatment and integrated as appropriate.For example, clients utilizing religiously-integrated therapies or relying on their religious beliefs and practices experience fewer depressive symptoms and faster recoveries (Koenig 2004;Koenig et al. 2015;McCullough and Larson 1999;Wink and Scott 2005), less anxiety (Koenig 2004;Rosmarin et al. 2010; Van Ness and Larson 2002), lower suicide rates (Koenig 2004;Koenig and Larson 2001), and lower overall mortality (Li et al. 2016).
Unfortunately, across helping professions, the integration of RS into professional education has been slow to be adopted (Oxhandler and Pargament 2014;Vieten et al. 2013).For clinical social workers, though education is the second largest predictor of practitioners' views and integration of clients' RS (Oxhandler et al. 2015), one-third of accredited masters in social work programs over the last decade have offered a course on RS and social work (Moffatt and Oxhandler 2017) despite half of practitioners reportedly being prepared to integrate clients' RS (Oxhandler et al. 2015).Similarly, only one out of four accredited clinical psychology programs offer a course on RS (Shafer et al. 2011).Other helping professions report feeling ill-equipped to address clients' RS struggles in treatment, including marriage and family therapy (Carlson et al. 2002;McNeil et al. 2012), nursing (Strang et al. 2002), and counseling (Young et al. 2007).
Interestingly, one of the largest predictors of practitioners' views and behaviors related to integrating clients' RS is their own intrinsic religiosity, regardless of their faith tradition (Oxhandler et al. 2015;Cummings et al. 2014).Further, spiritual or religious counselors tend to integrate more RS therapeutic behaviors with clients, affirm and communicate respect for clients' RS beliefs, solicit client feedback concerning the therapy they are receiving, and advocate for the self-determination and autonomy of religious clients (Frazier and Hansen 2009).
In response to an emerging pattern between the practitioners' RS (particularly their intrinsic religiosity) and their integration of clients' RS, Namaste Theory was recently developed (Oxhandler 2017).Namaste is a Hindi term that means, "the sacred in me honors the sacred in you" (p. 1).In essence, Namaste Theory posits that "as practitioners experience, are engaged in, become aware of, and infuse their own RS beliefs and practices into their daily lives-deepening their [intrinsic religiosity] and becoming more attune to the sacred within-they tend to hold more positive views and engage in clients' RS beliefs and practices as well.In other words, as helping professionals recognize the sacred within themselves, they appear to be more open to recognizing the sacred within their client".(Oxhandler 2017, p. 6) While recognizing the role of practitioners' RS is critical to this larger conversation, many helping professionals' RS beliefs and practices differ from clients' (Oxhandler et al. 2017;Kelly 1995;Shafranske 1996).Thus, it is important for helping professionals to be aware of their RS beliefs and practices, how they may differ from one another, and how they differ from the clients they serve.

RS Beliefs and Practices across Helping Professions
Few studies have explored RS beliefs and practices across helping professions.While practitioners tend to hold fewer traditional views in regard to their choice of religious affiliation, service attendance, and RS beliefs (Bergin 1980;Bergin and Jensen 1990;Hodge 2002;Oxhandler et al. 2017;Ragan et al. 1980), Bergin and Jensen (1990) offers one of the first studies to explore and compare the religious beliefs and practices across several helping professions.Among 425 clinical psychologists, psychiatrists, clinical social workers, and marriage and family therapists, 80% indicated a religious preference, with a majority selecting Protestant, and 41% attending religious service on a regular basis.The authors identified similar results among the general public, with 91% having a religious preference, and 40% regularly attending religious services.Across professions, marriage and family therapists consistently demonstrated the highest rates of religiosity, followed closely by clinical social workers.Psychiatrists and clinical psychologists held the lowest levels of religiosity and were least similar to the general public they served (Bergin and Jensen 1990).Though Bergin and Jensen (1990) offer an early comparison of professions' RS beliefs and practice, there have been a number of studies that have sought to understand each profession's RS beliefs and practices, as described below.
Psychologists.More than any other helping profession, psychologists' RS have tended to differ from the general public's RS.Psychologists are less likely to endorse a religious denomination (Roper Center 1991), believe in God, contain knowledge on the beliefs and practices of the Judeo-Christian faith traditions, and regularly attend religious services (Ragan et al. 1980;Shafranske and Cummings 2013).Though some report psychology's respect for the role RS plays in clients' lives (Shafranske and Gorsuch 1985;Shafranske and Malony 1990), others reveal negative views concerning RS (Ellis 1971) or explicit and implicit negative biases held by psychologists against religious clients (O'Connor and Vandenberg 2005;Ruff 2008).More recently, compared to the general public, APA members reported different RS affiliations than the general public-with more psychologists selecting Jewish-and were more than twice as likely to select no religious affiliation (Delaney et al. 2007).Further, while 48% of psychologists described religion as unimportant in their lives, only 15% of the general public felt the same (Delaney et al. 2007).Interestingly, psychologists tend to be more supportive of spirituality than religion (Shafranske and Cummings 2013).
Social Workers.Though clinical social workers' RS preferences and perceived importance in Bergin and Jensen's (1990) study more closely resembled the general population, recent studies indicate a markedly different trend.In Canda andFurman's (1999, 2010) national surveys of NASW members, compared to the general population, social workers were less likely to identify as Protestant and more likely to identify as Jewish, atheist, or agnostic.Similarly, compared to the general public, a national sample of baccalaureate and graduate-level social workers were more likely to endorse a liberal theological RS denomination, with graduate-level social workers being more likely than undergraduates to not hold RS beliefs or distrust organized religion (Hodge 2002).More recently, Oxhandler et al. (2017) compared a national sample of licensed clinical social workers' (LCSWs) RS beliefs and practices with the general population and found LCSWs are significantly less religious, more spiritual, and self-identify with different religious affiliations compared with the US population.Regarding religious affiliation, while 73.9% of the US population self-identified as Protestant or Catholic, 37.1% of LCSWs reported the same.However, more LCSWs identified as Jewish (21.6% vs. 1.5%),Buddhist (6.4% vs. 1.1%), or other (14.5% vs. 1.9%) compared to the general population.Equally, one out of five in either group selected no affiliation.Therefore, while social workers' RS might have once reflected the general public, recent surveys indicate clear differences.
Marriage and Family Therapists.As Bergin and Jensen's (1990) study indicated, marriage and family therapists' (MFTs) RS beliefs and practices tend to more closely resemble the general US population.In 2002, Carlson et al. surveyed AAMFT clinicians to assess professional and personal beliefs about RS and found an overwhelming 95% of respondents considered themselves a spiritual person, with 94% claiming spirituality as important in their lives.While fewer (62%) MFTs considered themselves religious, this still tends to be higher than other professions.Additionally, 71% reported participating in prayer on a regular basis and 82% claimed to consistently spend time connecting to their spirituality (Carlson et al. 2002).
Counselors.Though counselors were not included in Bergin and Jensen's (1990) study, a survey of ACA members' RS beliefs was conducted shortly thereafter.Kelly (1995) found that 64% believed in a personal God, 25% believed a spiritual or transcendent dimension exists, and 85% agreed to the importance of "seeking a spiritual understanding of the universe" (Kelly 1995).Follow-up studies within various regions also indicate the role of counselors' RS.Among Michigan Counseling Association members, 70% reported religion as important in their daily life, with 95% indicating the same about spirituality (Langeland et al. 2010).Interestingly, within the Southeast US, 94% of licensed professional counselors (LPCs) report an awareness of spiritual beliefs is significant in the counseling process (Hickson et al. 2000).
Nurses.Nursing has acknowledged the role of RS in patients' lives and developed protocols to ensure spiritual assessments and interventions are included in patient care (American Holistic Nursing Association 2007; Clark et al. 2003).While several studies in nursing document patients' desire for their spirituality to be acknowledged in treatment (Clark 2010;Puchalski 2004), nurses' attitudes about integration (Strang et al. 2002;Williams et al. 2011), as well as barriers to RS integration in treatment (Brush and Daly 2000;McSherry 2006;Vance 2001), little has been done to understand the RS beliefs and practices of nurses or to compare their RS with the clients' RS whom they serve (Chung et al. 2007;Taylor et al. 2014).

Current Study
Not only have few studies been conducted to capture helping professions' RS beliefs and practices, no study to date has simultaneously compared the RS beliefs and practices of five different helping professions, including social workers, psychologists, marriage and family therapists, nurses, and professional counselors.Thus, our guiding research questions are: (1) What levels of intrinsic religiosity and frequency of religious activities exist across these five professions, and how do they compare; (2) To what extent do these five professions consider themselves religious or spiritual, and how do they compare?; and (3) What are the religious beliefs and practices across these five professions, and how do they compare?

Methodology
To compare the RS beliefs and practices of clinicians across helping professions, we analyzed data drawn from a 2015 administration of the Religious/Spiritually Integrated Practice Assessment Scale to licensed helping professionals in Texas (Oxhandler 2016).Utilizing a modified version of the Dillman method (Dillman et al. 2015), a mix of letters and postcards were sent with a link to complete the online survey to 3500 individuals who were systematically randomly selected from Texas licensing lists, including 700 LCSWs, LPCs, LMFTs, advanced practice nurses (APNs), and licensed psychologists (PhD/PsyDs) with Texas mailing addresses.Due to a variety of reasons (e.g., bounce back letters or bad addresses), the sampling frame was adjusted to 3344 and 550 (16.5%) responded to the survey.
The survey included demographic items, several questions related to respondents' professional and educational experience, and our primary variables of interest-a battery of RS items.These items assessed religious affiliation, the extent to which respondents consider themselves religious and spiritual (Smith et al. 2014), which of nine common RS practices they frequently participate in (Oxhandler et al. 2015), and five items from the Duke University Religion Index (DUREL; Koenig and Büssing 2010).The first two DUREL items measure organized and non-organized religious activities, and the final three may be summed as a subscale to measure intrinsic religiosity.Using Likert-style response options ranging from one to five, respondents indicated how true the following were: (1) In my life, I experience the presence of the Divine; (2) My religious beliefs are what really lie behind my whole approach to life; and (3) I try hard to carry my religion over into all other dealings in life (Koenig and Büssing 2010).
For the current study, we restricted our analyses to 536 survey respondents belonging to one of five licensed helping professions in the state of Texas: LCSWs (n = 142), APNs (n = 74), LMFTs (n = 98), LPCs (n = 122), and psychologists (n = 100).To address our research questions, we conducted both descriptive and bivariate analyses.We first ran cross tabulations to compare patterns of response for variables of interest across the five helping professions.Frequencies and percentages for each variable and professional group are presented below.We conducted Chi-square tests to assess association between helping professions' categorical demographic and RS variables.We assessed the continuous demographic variables' various assumptions, and found the respondents' age, years in practice, years in their current setting, and their DUREL intrinsic religiosity subscale scores to not be normally distributed.However, given the sample sizes are fairly comparable with one another, and that the analysis of variance (ANOVA) tests are robust enough to handle data that is not normally distributed (Tabachnick and Fidell 2013), we proceeded with one-way ANOVA and a one-way analysis of covariance (ANCOVA) tests to compare means for age, years in practice, years in their current setting, and their intrinsic religiosity across helping professions.One-way ANOVAs were conducted to compare helping professions' continuous demographic variables and their DUREL intrinsic religiosity subscale scores.When comparing the DUREL scores, we controlled for age, years in clinical practice, and gender.Last, in order to examine the overlap of religion and spirituality in the lives of helping professionals, we ran Pearson's correlations to examine the relationship between self-reported religiosity and spiritualty within each profession.All analyses were conducted using SPSS 22.

Results
As a whole, professionals in the sample tended to be female (73.3%), White (78.7%), and middle aged (M = 51.55 years, SD = 13.05).All respondents held at least a master's degree, and almost a third (29.1%) held a doctoral degree.Individuals in the sample reported having worked in clinical practice for an average of 17.33 years (SD = 11.16) and in their current practice setting for an average of 10.72 years (SD = 9.19).Table 1 provides a comparison of descriptive characteristics across helping professions.Results of one-way ANOVA and Chi-square tests are reported where appropriate.
Next, we examined the religious and spiritual beliefs and practices of these helping professionals, with the results of each research question below.

What Levels of Intrinsic Religiosity and Frequency of Religious Activity Exist across These Five Professions, and How Do They Compare?
Chi-square results in Table 2 indicate significant differences in the intrinsic religiosity and frequency of religious activity across these groups.The first two items in Table 2 describe organized and non-organized religious activity-religious service attendance and participation in private religious activities.The results indicate some helping professions attend religious services and engage in private religious activities more frequently than others.The percentage of practitioners that attend religious services several times a month or more is highest among LMFTs (70.2%),LPCs (61.1%), and APNs (59.7%).LCSWs (55.9%) and psychologists (46.8%) (X 2 = 17.63, p < 0.01) more frequently reported rarely or never attending worship services.Regarding non-organized religious activities, those who participate in private religious activities once a week or more is highest among LMFTs (83.9%) and LPCs (81.6%), and lowest among psychologists (56.4%), (X 2 = 27.34,p < 0.001).A one-way ANCOVA compared helping professionals' intrinsic religiosity scores and revealed significant differences between professions (F[4, 472] = 3.26, p < 0.01).In the model, we included age, gender, and years in practice as covariates; however, age was the only covariate that was significant.

To What Extent Do These Five professions Consider Themselves Religious or Spiritual, and How Do They Compare?
Chi-square test results indicated no statistically significant differences among professions with regard to self-reported religiosity (Table 3).Over half in each profession considered themselves moderately or very religious, ranging from 50.7% (LCSWs) to 68.4% (LMFTs).In contrast to religiosity, there are significant differences in self-reported spirituality (X 2 = 11.33,p < 0.05) (Table 3).While a majority of respondents across professions considered themselves to be moderately or very spiritual, a particularly high percentage of LMFTs (95.8%) and LPCs (93%) considered themselves so.Finally, a moderate and significant correlation across helping professions was identified between self-reported religiosity and spirituality.

What Are the Religious Beliefs and Practices across These Five Professions, and How Do They Compare?
Though results indicated most practitioners in each profession identified as Christian, several significant differences emerged across affiliations (X 2 = 16.38,p < 0.05).Identifying as Christian tended to be most prevalent among LPCs (81.3%) and APNs (80.3%).In contrast, LCSWs (25.6%) and psychologists (24.7%), and LMFTs (23.7%) tended to self-identify with non-Christian religious groups more than APNs or LPCs.Likewise, not identifying with a religious group tended to be most common among LCSWs (12%) and psychologists (9.7%).

Discussion
Although few studies have sought to assess the RS beliefs and practices of any helping profession, this study is the first to assess and compare such beliefs and practices across five professions.Given that helping professionals' intrinsic religiosity is a primary predictor of integrating clients' RS in practice (Oxhandler 2017), it is critical their RS beliefs and practices be assessed and considered, particularly when it comes to training practitioners to be mindful of their own RS beliefs and practices-and how they may differ from other professions and the clients they serve-as they ethically and effectively integrate clients' RS.Further, several interesting findings emerged from the current study.
Most obvious is the marked tendency of APNs, LMFTs and LPCs to exhibit and express more traditional Western RS characteristics, such as their beliefs, practices, and affiliation, as compared with LCSWs and psychologists.Not only do APNs and LPCs tend to have higher traditional RS characteristics as compared with the other professions, but interestingly, a higher percentage self-identify as Christian compared with the general US population (73.9%;Smith et al. 2014).However, this may be due to this sample of helping professionals being in Texas, which is within a typically more religious US region.It was also interesting to see all five professions have a much higher rate of selecting a non-Christian RS affiliation compared to the US population (5.4%; Smith et al. 2014), with nearly a quarter of LCSWs, psychologists, and LMFTs self-identifying as non-Christian, and to see fewer "none"s compared to the general population (20.7%;Smith et al. 2014).This dovetails well with previous findings that many clients prefer their therapist to have some religious orientation, regardless of what it is or whether it matches the client's RS beliefs (Gregory et al. 2008).
Another noteworthy finding is the moderate correlation between self-reported religion and spirituality across all helping professions.This finding suggests that for many helping professionals in our sample, religion and spirituality are somewhat related concepts.In contrast, a recent national study comparing the RS of LCSWs with the general US population found that the link between religion and spirituality tended to be weaker for social workers than for the general population (Oxhandler et al. 2017).Our finding provides additional support for the idea that the population of helping professionals in Texas may be more traditionally religious than helping professionals across the nation.
Even so, there was some variation in strength of the correlation between religion and spirituality among helping professions in our sample.Further, the degree to which these professions consider themselves moderately/very religious is similar to the general population (54.2%;Smith et al. 2014), with LMFTs and LPCs tending to be more religious.What is exceptionally interesting is that a higher percentage of these professions view themselves as being far more spiritual (83.3%-95.8%moderately/very spiritual) as compared with the general population (65.1%;Smith et al. 2014).This result is bolstered by a majority of respondents across professions agreeing with the three intrinsic religiosity items (Table 2).
Finally, it was fascinating to see how engaged these professions are in various RS practices, even if they indicated they were not affiliated with a religion, as only 2.1%-15.1% of individuals across professions selected they do not engage in RS practices.Across professions, prayer was the most selected item (62.2%-84.2%),with attending religious services the second most common for all but LCSWs and LPCs.For LCSWs and LPCs, meditation and reading religious texts were the second most common practices, respectively.The frequency of RS practices then varied greatly across professions.What makes this so critical to recognize is that a recent qualitative analysis of LCSWs across the US indicated their personal RS (including beliefs and practices) was a primary source of support for integrating clients' RS in practice (Oxhandler and Giardina 2017).Thus, the variability of RS practices may influence what these various professions are recommending or including in their conversations around RS with clients.This ties into the importance of training practitioners on the ethical integration of RS.
Regarding training, it is worth noting that few helping professionals, across professions, reportedly took a course on RS during their professional training.While one in 10 LCSWs or psychologists took a course, two to three times as many APNs (20.8%),LPCs (26.1%) and LMFTs (30.9%) took a course on RS.Not only have helping professions communicated a desire for more training (McNeil et al. 2012;Oxhandler and Pargament 2014), but in recognizing the glaring differences between helping professions' RS beliefs and practices compared with the clients they serve, it is imperative such professionals be trained to understand, respect, and ethically integrate clients' RS-including those different from their own.Further, it's worth noting that even if practitioners identify as the same RS affiliation as their clients, that does not mean they hold the same beliefs or engage in the same RS practices.Similarly, a helping professional may self-identify as having a different RS affiliation as compared to a client, but engage in similar RS practices (e.g., a Christian client and Buddhist helping professional both practicing meditation on a daily basis).What is important is that these helping professionals be equipped to effectively and ethically assess for and integrate clients' RS.
Though this study has a number of strengths, it is not without limitations.First, the response rate was fairly low at 16.5%, limiting our ability to generalize the findings to licensed helping professionals across Texas.As described in Oxhandler and Parrish (2017), this is not uncommon for online surveys and could have been due to bias participants had against RS.Further, it is possible that those who were more religious/spiritual were more likely to complete the survey.However, a follow-up survey indicated reasons for nonresponse included a lack of time, being retired, or feeling as though it was not relevant to their practice.Additionally, this sample was limited to licensed helping professionals across five professions in Texas; therefore, these findings cannot be generalized to these professions across the US.Though we do not know whether or how LMFTs, LPCs, APNs, and psychologists' RS outside of Texas would differ, a previous study of LCSWs' RS across the US does indicate LCSWs in the South have different RS beliefs as compared to those in the West, Midwest, and North (Oxhandler et al. 2017).
Despite these limitations, this is the first study to simultaneously compare five helping professions' RS beliefs and practices.Future studies may consider comparing these helping professions across other states or doing a national survey of helping professions' RS beliefs and practices in the US or other countries.Further, it may be worth understanding if certain professions (e.g., MFT) tend to attract more traditionally religious individuals or those receiving training in ministry.On the other hand, other professions may attract individuals who are less religious (e.g., LCSWs).It would also be worth exploring whether there are disciplinary differences in terms of any messages graduate students receive related to RS during their training (positive, negative, or neutral), or how students are socialized into the profession as it relates to the topic of RS.Another consideration would be to see if any of these professions are more likely to have religiously-affiliated graduate programs, which could attract students who already self-identify as being more religious/spiritual, and/or potentially include more courses on RS.As these diverse helping professions continue to engage in transdisciplinary practice and interact with one another through referrals and serving clients, it is important to have a sense of each professions' trends regarding their RS beliefs and practices, especially as such professions are ethically mandated to recognize RS diversity in the clients they serve.

Table 1 .
Descriptive Characteristics of Helping Professions in Texas.

Table 2 .
Intrinsic and Extrinsic Religiosity among Helping Professions in Texas.

Table 3 .
Spirituality and Religiosity among Helping Professions in Texas.

Table 4 .
Religious Affiliation and Practices among Helping Professions in Texas.