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How helping professionals integrate the spiritual self in their work: qualitative research toward a working… Patterson, Pamela Frances 1998

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HOW HELPING PROFESSIONALS INTEGRATE THE SPIRITUAL SELF IN THEIR WORK: QUALITATIVE RESEARCH TOWARD A WORKING MODEL by PAMELA FRANCES PATTERSON B.A., Queen's University, 1990 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS  in  THE FACULTY OF GRADUATE STUDIES Department of Counseling Psychology  We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA April, 1998  In  presenting this  degree at the  thesis  in  University  of  partial  fulfilment  British Columbia,  of  the  requirements  of  department  this thesis for scholarly or  by  his  or  her  an  purposes may be  representatives.  It  is  permission for extensive  granted by the understood  that  publication of this thesis for financial gain shall not be allowed without permission.  Department of  GXJ^^I^  The University of British Columbia Vancouver, Canada  Date  DE-6 (2788)  ftpisl  -xq  ' f a r  advanced  I agree that the Library shall make it  freely available for reference and study. I further agree that copying  for  fe^ci^alo-g^  head of my copying  or  my written  ABSTRACT This project uses interviews and existential-phenomenological analysis to explore the question of how helping professionals integrate the spiritual self in their work. Chandler, Holden and Kolander's definition of spirituality (1992) divides personhood between the personal and the spiritual. This broad definition is used in exploring the research question with two helping professionals. The Co-researchers—a Doctor and a Therapist— are in the mid forties, they are well established in their professional careers and they are articulate in the research area. Two distinct modes of incorporating the spiritual self are identified. One is characterized by the healing of relationships described through a spiritual-psychological journey towards connectedness to self, other and god consciousness. The second mode of incorporation is characterized by an appreciation of transformation arising from an openness to the influence of spiritual reality in the process of therapy. Findings suggest that the professional's personal, professional and spiritual maturity is pivotal in the effective integration of the spiritual self. The need for integration of the spiritual self is in response to the extreme needs of the client population. The Co-researchers discuss that this is a needed area of discussion in professional circles. Further research into this area is necessary.  ii  TABLE OF CONTENTS Abstract Table of Contents List of Figures Acknowledgments  ii iii v vi  Chapter 1: INTRODUCTION AND BACKGROUND Introduction, Research Question and Overview History of the Spiritual Self in Counseling Early History A Reductionistic View of Human Functioning The Current Trend The Counseling Context The Person of the Counselor The Spiritual Self and Professionalism The Spiritual Self and Theory A Portrait of the Helping Professional Conclusion  1 3 3 4 5 6 9 9 12 14 19  Chapter 2: LITERATURE REVIEW Introduction The Spiritual Self is Central in Human Functioning Definition of the Spiritual Self. A Model of the Spiritual Self Counseling is Value Laden Theoretical Conceptualizations of the Spiritual Self Clinical Applications of the Spiritual Self Support for the Research Question Related Research Shafranske and Malony (1987) Millison and Dudley (1992) Cohen (1986)  21 21 25 27 29 37 52 67 70 71 72 72  Chapter 3: METHODOLOGY Introduction and Research Question Rationale for the Methodology Personal Bias Summary of Presuppositions Procedure Selection of Co-Researchers Pilot Interviews Co-researchers Interviewing Confidentiality and Consent Practicalities Second Interviews Material for Analysis Data Analysis Delimitations Trustworthiness of the Study  79 79 81 83 85 85 85 86 87 88 89 90 91 91 93 94  Chapter 4: RESULTS Introduction  97 iii  Exhaustive Descriptions Interview #1: The Integration of the Spiritual Self in Helping Professions is a Journey Premises of the Journey The Journey Practice Interview #2: The Integration of the Spiritual Self in Helping Professions is about Transformation Drawing On Deeply Personal Resources Spirituality Transformation's Three Elements Practice Common Elements General Observations The Spiritual Self Suffering Change The Therapist's Self is Pivotal in Practice Issues of Practice Limitations to integrating the Spiritual Self Training Additional Elements Statement of the Underlying Structure Introduction Interview #1: The Integration of the Spiritual Self in Helping Professions is a Journey Interview #2: The Integration of The Spiritual Self in Helping Professions is about Transformation The Common Experience of Integrating the Spiritual Self Chapter 5: FINDINGS AND DISCUSSION Introduction Major Findings of the Study The Personal Significance of the Spiritual Self. Two Constructions Of The Spiritual Self Two Distinct Conceptions Of Incorporating The Spiritual Self In Practice A Concept Of The Process Of Change Skills The Need For Professional Maturity The Client Population Professional Limitations Training Implications of the Study Future Research , Summary Bibliography Appendix A: Information Sheet For The Project Examining The Integration Of The Spiritual Self In Helping Appendix B: Consent Form Appendix C: Interview Guide Appendix D: The Invitation: A Poem given by B  iv  98 98 98 101 115 119 119 ..120 121 128 137 137 137 138 139 139 141 143 143 144 145 145 145 149 151 153 153 153 155 157 158 159 165 165 166 167 167 170 171 174 180 181 182 183  LIST OF FIGURES Figure 1. Model of the Self including the Spiritual Self.  28  Figure 2. Benner's (1988) Model of Spirituality  44  Figure 3. Chandler, Holden and Kolander's (1992) Model of Spiritual Wellness  60  v  Acknowledgments There are many people who have made the writing of this thesis possible. In many ways Dr. Westwood made the writing of this thesis into a real possibility. I am grateful also to my committee members Dr. Borgen and Dr. Neufeld for their encouragement and direction. I must also acknowledge my gratitude to my two Co-researchers who gave deeply of themselves out of their wisdom regarding this topic. The question about spirituality that underlies this thesis has shadowed me throughout my training. The remarkably rich responses I received has provided me with material that I continue to reflect on and draw strength and purposefrom.I feel that the additional learning I have gained as a result of the generous input of my Co-researchers is an invaluable gift to me as I embark on my own professional life as a Counselor. My dear family have worked tremendously hard on my behalf to see the completion of this thesis. Without the unfailing support of my husband Michael I couldn't have seen the completion of this long term ambition of mine. It has been a generous and sometimes costly gift. My young son Benjamin has helped me to keep my perspective on the things that are really important in life, like playing and hugging, going slowly and not getting too distractedfromliving. Finally, this thesis is dedicated to my unborn baby who's conception immediately preceded my proposal defense and who has patiently waited so far an extra ten days for me to finish this thesis before turning my attention to a different labor.  vi  CHAPTER 1 INTRODUCTION AND BACKGROUND  The purpose of this chapter is to provide background to the research question. Following an introduction and overview of the project we will consider the context of the history of the spiritual self in counseling. This discussion will include both the spiritual self in the history of counseling, and the relevant issues today. We will finally consider what the incorporation of the spiritual self might entail with respect to the counselor. This last discussion is an extended metaphor which raises some considerations regarding what the professional may be considering in incorporating the spiritual self in their work.  Introduction, Research Question and Overview This thesis considers how helping professionals' sense of the human phenomena of the spiritual self impacts their theoretical, practical and professional work. The research question was addressed through semi-structured interviews with two helping professionals who have integrated the spiritual self into their work. This thesis asks the question: How do helping professionals incorporate the spiritual self in their work? Examination of this question raises many related questions: What is the interaction between theory and spirituaUty? How do convictions concerning the spiritual self affect one's view and experience of their professional responsibilities? How does the spiritual self affect one's view and experience of clients or patients? The analysis of the data will use existentialphenomenological methodology leading to an atheoretical representation of the experience. Many have noted the necessity of integrating spirituaUty into helping (Aldridge, 1993; Bermer, 1988; Bergin, 1988; Chandler, Holden and Kolander, 1992; Grimm, 1994; Kelly, 1994; Mack, 1994; Westwood, 1995 ). Considering the need for helping professionals to incorporate spirituaUty in their research and practice, Chandler, Holden  1  and Kolander (1992) note: '"Awareness is wider and deeper than anyone had guessed; intention more powerful. Clearly, human beings have not begun to exploit their potential for change' (Ferguson, 1980, p. 154). Let this statement be a challenge to counselors to pursue spiritual wellness and development for themselves and for their clients in the decade of the 1990s and beyond" (p. 174). It is hoped that through this study helping professionals can begin to meaningfully incorporate their understanding of the spiritual self. The spiritual self has been a topic of discussion by numerous authors, though operational definitions of spirituahty have rarely been forthcoming. It is largely for this reason that little research has been done. Despite the lack of research, theorists have often incorporated a concept of transcendence within their theories finding this perspective more representative of human experience than more mechanistic constructions of human functioning. In the literature authors have emphasized the tremendous importance of the spiritual dynamic in healing, in understanding human nature, and in therapeutic encounters. The spiritual self has also gained social attention. Mack (1994) comments on the fact that spirituahty has become a topic that is discussed in numerous contexts and academic disciplines. "The growing use of the word spirituality in academic disciplines, in popular literature, and in therapeutic groups has transformed a once theologically laden concept into a descriptor of multifarious capacities" (p. 15). North American culture is now seeing widespread and growing interest in spirituahty as the limitations of the age of technology are revealed. Research in the area of the spiritual self for helping professionals however is insufficient to address the renewed attention. In considering the domain of counseling, the client in the counselor's office may be significantly influenced by their spirituahty. As the spiritual self has to do with reaching beyond present experiencing, the client in pain who knows there is the possibility of healing is drawn to the counseling office in part because of the faith born of that spiritual  2  self. Wishes, hopes, beliefs, affiliations, convictions and the yearning for meaning all have to do with the spiritual self, and all of them play an integral role in transformation. The counselor on the other hand also lives from within her or his spiritual self with its associated beliefs. Is the counselor in a conflicted situation? The question of how the counselor's involvement with a spiritual life affects his or her work with this client is relevant. Can the counselor truly set aside his or her convictions as professional training suggests, and be open to work with this client to achieve the client's goals for health and functioning? The literature suggests that this cannot be done (Bergin, 1980; Strupp, 1980; Weiskopf-Joelson 1980). How then can the Counselor attend fully to the Client? The spiritual self is actively engaged in the counseling process, yet there is little known about how to incorporate the spiritual self meaningfully either as a counselor or with a client. The concern regarding inappropriate indoctrination of values, the possibility of minimizing the client's spiritual self, the chance of neglecting to address primary and motivational aspects of the client's experience of spirituaUty aU chaUenge the counselor. Research, theoretical training and knowledge of techniques and interventions that address the therapeutic relationship at this central level remain largely unexplored in the counseling literature. These two or more people in the counseling office sit face to face and this central area of human experiencing is either disregarded or not satisfactorily understood and incorporated. To engage more fully in a therapeutic relationship we need to better understand how to integrate the spiritual self in our work.  History of the Spiritual Self in Counseling Early History Entralgo (as cited in Benner, 1988) has traced the earUest roots of contemporary psychotherapy to the ancient Greek rhetoricians. Early Greeks and Romans viewed the philosopher as the physician of the soul. Plato, for example, discusses the value of rhetoric and catharsis in soul care. The Greek rhetoricians used words as tools to persuade,  3  challenge and guide people towards the Greek ideal of perfection. Socrates is reported to have said " [I] spend all my time going about trying to persuade you, young and old, to make your first and chief concern not for your bodies nor for your possessions, but for the highest welfare of your souls" (Benner, 1988, p. 18). Of the necessity of a therapist-client relationship Cicero (106-43 BC) writes: "The soul that is sick cannot rightly prescribe for itself, except by following the instruction of wise men" (Benner, 1988, p. 23). Of note here is the word "wise" as opposed to "intelligent" or "knowledgeable". Wisdom suggests the property of intellectual knowing but also a deeper knowing which has to do with human soul. Benner (1988) notes that other than the Greeks and Romans, most cultures have framed soul care as the property of religious care. This has been done since the times of the ancient Semitic cultures and has taken various forms. The consistent factor of soul care has been "the sustaining and curative treatment of persons in those matters that reach beyond the requirements of the animal life" (Benner, 1988 p. 19). In light of this comment, the connection between soul care and the contemporary practice of psychotherapy is clear. Further, it is possible to see the connection between ancient practices of religion and psychotherapy. This second connection has been problematic in the history of psychotherapy with respect to the incorporation of the spiritual self in practice. A Reductionistic View of Human Functioning The seventeenth century saw the rise of science and the nineteenth century saw the decline of religion. Aldridge (1993) suggests the importance of these changes in our modern practice of medicine and the resultant view of health and suffering. Understandings of the body and its relation to illness were...transformed in the seventeenth century by the ability to dissect corpses (Foucault, 1989), which led to a new classification for disease. Supernatural explanations and causative forces were rejected in favor of theories within the realm of material phenomena as seen in the status of the internal organs. However, what was missingfromsuch observations of the dead were the vital forces necessary for living. Academic medicine in the universities was similarly separatedfromthe empirical practice of clinicians observing the effects of their ministrations. Any understanding that the human body could be organized by subtle forces, and represented the presence of a  4  higher intelligence in the universe, was abandoned. (Hossein, Nasr, 1990, p. 1516). (p.19) The removal of the spiritual dimension in the science of medicine has had the broader effect of conceiving health as simply the absence of sickness, and suffering as merely physical ailment. It is interesting to speculate on this conceptualization of health and suffering in light of the social taboos regarding mental illness and the client's sense that they should be able to handle their problems alone. One effect of the dissection of personhood brought about by this preference of science over spirituaUty is the Umitation of science to describe human experience. That science is inadequate to describe the encounter of persons and to capture the process of counseling is repeatedly noted in the Uterature (Chandler, Holden & Kolander, 1992; Giorgi, 1984; Mack, 1994; Tjeltveit, 1989). Further, the social preference for a scientific model of health which denies the spiritual element of experience is linked to our present inclination to spiritual cynicism. Snow & Willard (1989) discuss this tendency to believe in nothing; not in trust, honesty, intimacy or even deep friendship. Spiritual cynicism is the current social beUef in nothing and no-one greater than ourselves alone. Spiritual cynicism they say is an induced reaUty and related to the epidemic of addiction in North America. The loss of reaching meaningfuUy beyond ourselves to some greater purpose is the loss of a basic human function that precipitates health (Yalom 1982). The Current Trend Despite the effects of this loss of a spiritual perspective in our society, effects which could include addiction, violence, racism, abuse, neglect, the vast majority of Americans report a continued belief system. More than 90% of the United States population profess some form of beUef in a Transcendent Being (Pate & Bondi, 1992). Smith (as cited in Pedersen, 1995) discusses the turning point that has led to this revival. "Dismayed by the relentless utiUtarianism of technological society and its seeming inabihty to contain its power to destroy both people and planet, citified peoples have come to hope that a fundamentaUy different way of Ufe is possible, and they latch onto primal peoples to  5  support that hope" (p. 4). The focus on primal peoples is related to a focus on the central place of spirituality in their lives. Pedersen (1995) describes the revival of religion to a place of significant power today. Interest in religion has risen recentlyfromthe popularity of Eastern religions in the late 1960's and early 1970's to the prominence of organized religious groups in the political arena in the 1980's and 1990's, the popularity of new religions and cults among the disenchanted and excluded, the appeal to moral and religiously flavored arguments in the public discussion of social issues such as abortion, Equal Rights, and the appeal to religious truth as a moral standard in judging the betrayal of public trust in the Watergate, Iranscam and other scandals. The fiscal viability of televangelism and the sensitivity of public figures, from political leaders to terrorists, justifying their positions according to religious evidence demonstrates the strength of contemporary religion, (p. 5) The Counseling Context. We have looked at the historical association of spirituaUty and psychotherapy, the evolution of the reductionistic view of health, and the current social response in the direction of change. Perhaps as a result of the Umitations of scientific reductionism, the helping professions have been slow in effectively incorporating a professional understanding of the current spiritual revival. In general it has been the practice for helping professionals to ignore client's spiritual issues and attribute them to pathology (Peterson, 1987), an approach which is traced back to Freud's, among others, summation of religous belief as pathological. In the counseling community we have embraced the scientific model and have consequently been without a means to see or address the spiritual element of our CUent's and our own experiences (Benner, 1988; Jensen and Bergin, 1988). As Ehrenwald (1966) observes; 'With the soul displaced by the mind and the mind regarded as a function of the brain, psychotherapy came to be regarded by many as a medical act" (p. 28).The spiritual component of the counseling process has remained largely unconsidered in counseling practice though it can be seen that it is very much a part of counseling practice. In fact the historian Neaman (as cited in Benner, 1988) argues that the responsibiUties of the mental health professions have moved from treatment of mental illness to aids in spiritual struggles.  6  Our professional failure to see the importance of integration of both scientific and spiritual understanding of human functioning is also reductionistic. The lack of an integrated view is seen in the friction sometimes experienced between the discipline of psychology and the religious traditions. Grimm (1994) states that "religious and spiritual values systems and the epistemic systems of psychology have long been opposed to one another. Many religious institutions and individuals have viewed psychology as a worldly competitor for influence over persons" (p. 156). Lukoff, Lu and Turner (1992) describe the tendency in psychiatry to devalue religion and ignore spirituahty. For its part, the psychology literature, while disavowing the relationship with religion, claims to have replaced religion socially with a more suitable alternative, thus conveying the fundamental connection, and perpetuating the friction between the two (Ehrenwald, 1966). The failure of counseling programs to incorporate spirituality is documented (Kelly, 1994). The specific reasons for this oversight are unknown but in light of the history of failed communication between religious and scientific paradigms, it is not difficult to surmise that uncertainty has played a part. Pate and Bondi (1992) argue that religious belief is an integral aspect of culture. As a result it has direct implications for knowledgeable work with clients. Further, they argue that, as a portion of their training in self awareness and self discovery, students of counseling need to understand the impact of their spiritual beliefs on the counseling process and must be able to recognize the limits of their practice based on their views. Counselors they argue must be sufficiently comfortable with their own views that they can comfortably explore the religious and spiritual issues of their clients. With respect to this Kelly (1994) has found in a study of North American Colleges that a very small percentage of colleges actually give their students any training in dealing with spiritual and religous issues. Counseling needs to find its own place situated rightly in relationship to both science and spirituality. Through the use of qualitative research whereby we can explore deeply intra-personal experience the possibility of incorporating the spiritual dimension has  7  become not only possible but necessary. "For counselors, the challenge of the 1990's is not whether issues of spirituality, values and ethics should be addressed, but how they can best be handled" (Miranti and Burke, 1992, p. 4). Efforts at integration have already begun in significant ways, one worthy of notice is the address of the President of the American Psychiatric Association to the Pope: The president of the American Psychiatric Association has asked Pope John Paul to "help us to achieve greater collaboration between religion and psychiatry." The "new knowledge and learning of each can benefit the other, and most of all, the patient," Joseph English said in a special audience with the Pope. (Vatican City (AP), 1993, p. H7) As we have now come to the place of considering the integration of a scientific and spiritual perspective it is necessary to consider what this might look like. Aldridge's (1993) discussion of healing suggests the limitations of our understanding and points to the issues of incorporation of a spiritual perspective in healing. Neither of the orthodox traditions, be it church or medicine, can explain how healing occurs.... Our spiritual understanding of the intention of healing is largely lost....Miracles had a deeper purpose than the restoration of physical health. It is not that the age of miracles is past, rather that their spiritual significance is no longer understood and has been supplanted by material and emotional satisfactions alone (Shah, 1964)....Perhaps what is more important, we systematically fail to define health, (p. 19) In incorporating a spiritual perspective, Aldridge goes on to suggest that transformation is the potential inherent in the journey of suffering and healing. Certainly we understand that there can be great health in the person who is suffering as there can be great suffering in the person who appears healthy. What is suggested here is a different view of health, healing and suffering which recognizes that change is intimately connected to a spiritual journey of transformation. Considering the helping professions specifically, "the task of the to direct the attention of the patient, through the value of suffering, to a solution that is beyond the problem itself—the idea of transcendence" (Aldridge, 1993, p. 18). Counselors arerightlycriticized for attempting to eliminate rather than work for the transformation of their client's pain. What is needed to transform the current understanding of healing is a different understanding of the work of the helping professional.  8  In conclusion, in the process of the evolving identity of counseling somewhere between pure science and pure religion, yet implicitly neither, the incorporation of spirituality is a necessary inevitabihty. We need to recognize that patience, grace, prayer, meditation, hope, forgiveness and fellowship are as important in many of our health initiatives as medication, hospitalization, incarceration...[and] surgery . The spiritual elements of experience help us to rise above matters at hand such that in the face of suffering we can find purpose, meaning and hope (Hiatt, 1986). (Aldridge, 1993, p. 4) Considering the implications of this professional perspective is the task of this project. Following is a discussion of the implications of integration of the spiritual self for the professional.  The Person of the Counselor The onus is clearly on the counselor to recognize the importance of the spiritual self and to incorporate it with integrity to the end of enhancing skills and facilitating the client's or patient's healing process. We conclude this chapter then with a discussion of the person of the helping professional who incorporates the spiritual self in his or her work. The discussion is in three parts. Firstly we will consider the effects of the spiritual self on the professional role, secondly on theory. Finally using Harrison's (1988) offering of Dante's Virgil as counselor we will illustrate the integration of the spiritual self in helping. The Spiritual Self and Professionalism To begin with we consider the plight of helping professionals dealing with a body of changing knowledge, roles and responsibilities. Sims (1994) outlines several reasons why psychiatrists ignore the spiritual: (a). It is considered unimportant; (b) It is considered important but irrelevant to psychiatry—like assuming the hospital has a safe water supply; (c) We feel we know too little about it ourselves to comment or even to ask questions; (d) The very terminology is confusing and hence embarrassing; it is not respectable; (e) There may also be an element of denial in which it is easier to ignore this area than explore it as it is too personally challenging, (p. 444) The same awkwardness characterizes the challenge to Helping Professionals in a scientific paradigm who are now, due to the identified health benefits and because of changing social 9  norms, needing to examine exactly how to incorporate the spiritual self in their work. What Sims' comments demonstrate is the lingering ambivalence regarding the right place of the spiritual self within the context of helping, and the sense of uncertainty professionals experience in the changing face of their work. Professional helpers are without demonstrated methods of application, or understanding of the implications of the incorporation of the spiritual self in their professional roles. This problem brings us to the central question of this project. A facet of this professional awkwardness is the issue of paradox. In the following quote Walter (1994) outlines the internal paradox for professional helpers who incorporate the spiritual self in their work. He poses the question of the relationship between the spiritual self and the role of the counselor. During my career as therapist I have never asked my clients to work on koans. I have rarely recommended meditation practice, and I have not even discussed Buddhism with many of my clients....Yet I can say without qualification that what I have realized through my Zen practice is the foundation of my life and my therapy practice. It pervades my activity and informs my interventions. Without it I would be lost. I do not know how to explain the connection between my Zen practice and my therapy practice (p. 43). Walter demonstrates that he knows the pervasive influence of his spiritual self in his life and in his work, yet it remains an evasive relationship for direct description. The Coresearcher for a pilot interview commented similarly that the spiritual self is "the core of our very being" yet she also noted that it is a background issue in counseling. This is the dual reality of the spiritual self in the counseling context: core, yet in the background; central, yet in some ways peripheral; profoundly influential in the counseling context, yet perhaps never directly discussed. Of course the spiritual self is at times a topic of direct discussion in counseling, but in general it is the posture of the helping professional to both know its influence and not necessarily directly address it. This is an acknowledged bias of the helping professional who integrates the spiritual self, yet this bias is supported by clinical research and experience (Kelly, 1994; Pate and Bondi, 1992; Sims, 1994; Walter, 1994). 10  Helping professionals who incorporate the spiritual self into their work recognize that focusing simply on human resources in healing or change is limited. That is, there must be more than will power, good wishes and determination that lead to the transformation characteristic of deep healing. Referring to Dante's journey through purgatory which she connects to the counseling process, Harrison (1988) notes that Dante cannot do his striving alone with his counselor Virgil. "He himself is aided by Beatrice, Lucy, and several varieties of angels. Too many obstacles and dangers exist on the journey and the path is sometimes too steep to be traversed with only rationality and good intentions" (p. 317). Harrison points to the fact that our healing journey is limited by our categorical idea of knowledge and needs to be enhanced by the vast and eternal potential of our spiritual lives. Our designated helping professional then, works with reliance upon this greater influence in working with clients. When a Client refers to an angel who supported them, or to a sudden and mysterious freedom to relinquish something, the helping professional can recognize a profound movement of the client towards transformation and healing. This reality is not technique based and is beyond the counselor's authority or jurisdiction. The helping professional who incorporates the spiritual self in their work is given the gift of witnessing an element of profound change without having to pathologize, or negate it. Another Coresearcher for a pilot interview, an artist, described the experience as having the skills, the tools and the materials, but being utterly reliant on the spiritual for the piece to achieve a life of it's own. Acknowledging the helping professional who incorporates the spiritual self in their work has radically undressed the icon of power often characteristic of professional roles. With respect to power, there is a strong social tendency to view those in positions of responsibility in unrealistic terms. Several authors (Harrison, 1988; Sims, 1994) have noted the tremendous authority, sometimes that of gurus or gods, which society in general and clients in particular tend to attribute to helping professionals. In a necessary contrast,  11  counselors who incorporate the spiritual self, work closely with the deep awareness of their simple humanity, and their role as catalysts or companions with their clients. " We need to balance the importance of the spiritual in the life of our patients with denying absolutely any sort of priestly role for ourselves" (Sims, 1994, p. 445). It is a case of being clear regarding our identity within ourselves, in relation to our clients and in society at large. The Spiritual Self and Theory For the helping professional who incorporates the spiritual self, there is the level of theoretical knowledge and there is a further acceptance and experience of the spiritual. Working to be discerning and professional in the application of analysis based on well considered theory and technique, the helping professional relies also, and at a more fundamental level on the "movement of the spirit" whereby change can be experienced and integrated. Cohen (1986) for example, makes the mistake of looking at psychoanalysts who are also religious through the lens of psychoanalytic theory. From this perspective he finds them unable to defend their position. My contention here is that for the helping professional who integrates the spiritual self in their work, the spiritual self has a prior reality to the theory. This in no way negates the theory, but neither does it suggest that the theory should be able to encompass the spiritual self which is in some way eternal. If Cohen's Co-researchers were unable to defend their positions it was because he was demanding a difficult task. The Co-researchers could not use theoretical language to defend their spiritual positions. As an illustration, Walter (1994) describes the transformation characteristic of Buddhist enhghtenment: You will feel as though the whole universe has totally collapsed. Strange as it may seem, this experience has the power to free you from the agonies of the world. It emancipates you from anxiety over all worldly suffering. You feel as though the heavy burdens you have been carrying in mind and body have suddenly fallen away. It is a great surprise. The joy and happiness at that time are beyond all words, and there are no philosophies or theories attached to it. This is the enhghtenment, the satori of Zen. Once you have attained this experience, you will become perfectly free, (as cited in Walter, 1994, p. 42)  12  This experience transcends the capacity of theoretical or technical applications. It clearly has to do with the spiritual self. It also clearly has the ingredients of deep healing: joy, happiness and freedom. The illustration is an extremity of spiritual experience but it is not an experience Umited to certain persons. To ask a person to defend this spiritual transformation in the language of theory would be to reduce the experience to virtual meaninglessness. Notably in this regard, Herman (1993) has noted that knowledge, training, theoretical orientation and experience in counseling have a negligible effect with respect to positive therapeutic outcome. Paraprofessionals can be as effective as professional counselors. We also know that significantly fewer professionals practice a religious life than the general population (Bergin and Jensen, 1990). In light of the present discussion one wonders whether the paraprofessional offers spontaneously a spiritual dynamic which confounds the professional. Another effect on theory of holding a view of the spiritual self in helping is that the counselor is familiar with the process of suffering as it is related to healing. That suffering is a common part of human experience and that suffering can also be the catalyst of transformation is understood and experienced by the helping professional. This is in contrast to what can happen in counseling where the theoretical objective is the eradication of a problem. The effect of this common theoretical view is a functional robot rather than an ordinary person immersed in the common dynamics of life. Ultimately one needs to engage the dynamics of living rather than focus on mastering every Umitation. Aldridge (1993) argues that the medical profession systematically fails to define health. The same can be observed in counseling hence the cardboard-person product. The spiritual self affects theory to become inclusive rather than reductionistic. Suffering is seen not as an enemy; it is a part of living and, in some cases, it can be a gift.  13  A Portrait of the Helping Professional The following discussion is afreestyleexploration of what the experience of being a helping professional who incorporates the spiritual self might look like. The illustration is taken from Harrison's (1988) interpretation of Dante's Purgatorio. The story is of a spiritual journey through purgatory. It is useful in this context because the "Client" Dante, is on an explicitly spiritual journey accompanied by his "Counselor" Virgil. Helping professionals who incorporate the spiritual self may view their clients as being on such a journey hence the proposed model of Virgil is fitting for our discussion. Harrison (1988) portrays the counselor Virgil as " a pagan poet beloved for his rationality and his sensitivity to spiritual truth" (p. 314). There are four elements of note in her description: (a) the counselor is a poet, (b) he or she has the endorsement of his or her community; note that Virgil is beloved (c) he or she is rational, and (d) he or she has a sensitivity to spiritual truth. To embellish our illustration of the counselor, we will consider each of these elements. First of all, the Poet and the counselor share the skill of a conscious use of words to express experience. Secondly, counselors like artists, look profoundly within themselves at their subject and at their world in order to reflect experience. Finally there is the meaningful and skilled interaction of artist and medium, or counselor and client to effect some unique creation. This is not to suggest that the client is a project, but that together the counselor and client work in the client's creation of something new. The counselor's art is in facihtating that process. In counseling this creation has the effect of healing both the counselor and the client; in art the healing occurs for the artist and the audience. "Soul gives us art, and art gives us soul; they both take us to, and saturate us with Being" (Elkins, 1995, p. 87). The Counselor in the Community. Returning to the discussion of Dante's journey Harrison (1988) notes Because openness is essential for the re-estabhshment of integrity and intimacy, purification always occurs in the public on the mountain of 14  Purgatory....Community, which was lost with Adam's fall, is restored—not only by the comfort, support, and simulation provided by others undergoing purgation on the same terrace, but also by the prayers of those on earth and in Heaven who intercede on behalf of specific individuals experiencing purgation. Furthermore, the prayers of the church sung on each terrace connect the souls in a mystical manner to God and to all believers who have passed that way before. No soul can feel 'lost' in such a context, (p. 316) What is beautifully captured in the above quote is the individual's healing journey from isolation back into integrity and intimacy facilitated by the connection with a community. The counselor in this portrait is one piece in a large puzzle which includes the individual, their social environment and their spiritual life. The counselor's ability to be connected to that community is a link for clients as they pursue their journey towards wholeness. That Virgil is beloved by the community reflects his ability to communicate at a personal and a community level in a way that captures peoples' experience. He is vitally in touch with his world. On the other hand as the community in this metaphor is aware of the client's experience, so also the counselor is also connected to his or her client. This is like the counselor who captures the client's experience to the end of bringing them back in touch with his or her world in a healing way. As the counselor works with the client in understanding his or her particular "community of suffering" a re-connection with their world is possible. Thus the counselor plays a significant role in community building. The Counselor as Rational. The third point, that Virgil is rational, is in the domain we are most familiar with, and is of course essential to the practice of counseling. It is not our intention to compromise this necessity in any way other than to challenge traditional thinlcing regarding the spiritual self. The following discussion offers some thoughts regarding rationalism. Counselors who have incorporated the spiritual self within their own lives have the perspective that the spiritual self underlies everything. We take Frankl's (1988) words for example: " It is my contention that man really could not move a limb unless deep down to the foundations of existence, and out of the depth of being, he is imbued by a basic trust in  15  the ultimate meaning" (p. 150). Meaning in Frankl's work is the goal of our spiritual selves. The necessity for the counselor then becomes the thoughtful inclusion of the client's spiritual self in the context of counseling. This may mean for example becoming somewhat knowledgeable regarding the client's religious training, or as Sims (1994) suggests, exploring the client's experience of their religion or their spiritual selves using familiar counseling techniques. Sims (1994) suggests that it is the combination of the counselor's endorsement of his or her own and the client's spiritual selves that enables the counselor to determine the extent to which the client's spiritual or religious life impairs the client's functioning. Sims notes that "differences become evident between the self-experience [italics added] of magic from that of ritual or faith, in a similar way to the psychopathological differences between obsession, delusion, and over-valued idea" (p. 441). A client's introduction of a spiritual perspective with professionals who either reject this aspect of human experiencing or who have not effectively incorporated it into their work, may have the effect of distancing between the counselor and client. Griffith (1986) for example states that "witnessing the religious faith of another can uncomfortably heighten the observer's awareness of his or her own faith, or non-faith, as grounded in psychological experience rather than compelling logic, which leads to a natural impulse of anger toward the client" (p. 617). Grimm (1994) notes that counselors may experience more friction than their clients in the area of spirituality because of the clash of ideologies. This is an important consideration for practitioners as it may indicate how deeply influential and valued our experience of the spiritual self is. It is a powerful and delicate matter to bring into the context of helping. Learning about its appropriate incorporation into the helping relationship is an area where more research is needed. Another aspect of the rational nature of the incorporation of the spiritual perspective into helping is the nature of professional knowledge. Numerous authors (Benner, 1988; Tjeltveit, 1989) have noted that the practice of counseling, because it is encounter, exceeds  16  the researched domain of psychology. Consequently professionals are required to rely on more intuitive understanding at times. For the professional who incorporates the spiritual self in his or her work, this may involve some tendency to lean on their own spiritual training or knowledge. Herman (1993) points to the need for professional counselors to rely more on research to enhance the difference between professionals and paraprofessionals in creating positive outcomes in counseling. This is certainly a necessary responsibility for all counselors. For the helping professional who incorporates a sense of the spiritual self however, there may be a sense that research does not entirely capture the process of counseling. Thus the interaction between the spiritual self and science continues. The Counselor's Spiritual Sensitivity. The final area of discussion in this consideration of Virgil as the model for the counselor is Harrison's (1988) comment regarding Virgil's spiritual sensitivity. In an earlier section we discussed the evolution of counseling within the confines of religious institutions. Benner (1988) records the story of the Russian "startsy" or "old man" who acted as spiritual guide to the parishioners: The startsy took as his role model Christ the good shepherd. The primary function of the good shepherd was his willingness to suffer for and along with the sheep. Consequently the startsy had to be one who had the ability to love others and to make the suffering of others his own. This notion of vicarious suffering on the part of the physician of the soul has tremendous implications when the startsy is recognized as a precursor of the modern therapist. The psychotherapist cannot remain aloof from the suffering of his or her patient. Rather, the therapist must incarnate himself or herself, and entering.into the very heart of the patient's chaos and suffering must often vicariously experience and absorb that suffering, (p.23) From a Christian perspective the above illustration of the startsy, using Christ as the model, and the concept of the counselor incarnating the client's experience are clearly spiritual endeavors. In a similar way Walter (1994) incorporates his meditations with Buddhist koans in his work in a personal way. It is perhaps in this way that helping professionals who incorporate the spiritual self in their work maintain their spiritual sensitivity. By strongly allying oneself with one's own spiritual pursuit, counselors can bring this  17  sensitivity to their work with clients. Walter comments further regarding the centrality of his spiritual practices in relation to his work. Finally, Harrison (1988) notes that, while Virgil is not Christian as Dante is, this in no way detracts from Virgil's skill as Dante's guide. As an aside, Virgil's paganism points to an earthy love of life which is fitting for the counselor who is so vitally involved in life in their work. The process of counseling however, does not incorporate spiritual instruction but creates "an interpersonal environment within which the client is free to make choices; that is, the therapeutic setting is not coercive, but enablmg—offering an opportunity for change but not enforcing it" (Harrison, 1988, p.314). In fact Frankl (1969) argues that Logotherapy, and we would argue that counseling in general, needs to remain available to everyone. Counseling, as we have discussed, is not the forum for teaching rather it is the place for individuals to explore their life journeys and determine their responsibility in their lives. Clients may choose helping professionals based on their known spiritual convictions, however the territory of their work together is the client's individual experience of his or her own life. We will later discuss how the client's experience of his or her spiritual life is in any case a highly personal journey. These last two points — that the counselor works between the disciplines of rationalism and spiritual sensitivity — can be seen to relate to the conflict sometimes experienced between religion and psychology. Benner (1988) discusses the fact that psychotherapy straddles religion and psychology. He comments that psychotherapy relies on the spiritual self. On the other hand psychotherapy appropriately is situated in the world of science; observation, research—in essence it straddles the two and in its different theoretical approaches it goes further in one direction or the other. The task for the Counselor here is to know clearly where they stand including their personal, theoretical, and scientific limitations, (p. 28-29) In the final analysis it is the role of the individual counselor working within his or her personal dynamics of spirituahty, scientific practice, love of life and community to work with the diversities of religion, spirituality, rationalism, ethics, values, research,  18  psychology and so on, in order to fashion his or her professional work in an integrated and healthy way. In summary, Helping Professionals who incorporate the spiritual self in their work have incorporated an attitude of reflection on life and community, a respect for the practical disciplines of their work, reverence for their own and their Client's spiritual lives, and an attitude of openness and frankness in relation to the world. Counseling using an incorporation of the spiritual self appears to straddle the disciplines of science and religion, but, in fact, it is a different kind of journey which is deeply personal for the professional in working through his or her own understanding of his or her world openly, with integrity and boldness. "May says, the spiritual quest is a search for our roots, not the roots of family, nor of race, nor even of the human species, but our roots as creatures of and in this cosmos" (Benner, 1988, p. 70). Humbly, gently helping professionals go about this pursuit in their own lives, and professionally, they create space for their clients to also pursue this journey.  Conclusion Hillman's comment provides a final statement regarding the importance of the spiritual self in the helping professions. "Where there is connection to soul there is psychology; where not what is in its place is better called statistics, physical anthropology, cultural journalism or animal breeding" (as cited in Elkins, 1995, p. xii). We have examined the history of counseling in light of it's relationship with the spiritual self, and the current professional problem of reductionism in a social climate which is reclaiming spirituaUty. We have also considered the issues related to integrating the spiritual self in the counseUng context. From our discussion it is apparent that the helping professions need to reconsider the integration of the spiritual self in counseling. We finally examined the issues of integrating the spiritual self as they arise for the individual professional. We concluded with a metaphorical illustration of what the incorporation of the  19  spiritual self might look like for the helping professional. This is a prehminary glimpse of what the research question is asking and forms a premise from which the literature can be reviewed to consider the dynamics of how a helping professional might integrate the spiritual self. It is apparent from the foregoing discussion that the integration of the spiritual self in practice demands professional attention regardless of whether this need is considered from a social, professional or personal viewpoint.  20  CHAPTER 2 LITERATURE REVIEW  Introduction The purpose of this chapter is to review the literature related to our discussion of the spiritual self. The literature review is broad as many issues converge in incorporating the spiritual self in helping. The first area of discussion considers the place of the spiritual self in human functioning. This discussion begins with the definition and model of the spiritual self used in this project. The second area of discussion examines the dynamics of introducing a value based professional position implied by integrating the spiritual self. The remainder of the chapter will convey the three elements of theory, practice and research whereby the spiritual self has been used in the practice of counseling by professionals.  The Spiritual Self is Central in Human Functioning That the spiritual self is central in human mncuoning is a central assumption of this research into how helping professionals incorporate the spiritual self in their work. Careful consideration of this assumption then is necessary for the purpose of credibility. Benner (1988) finds that there are three positions to be taken with reference to the spiritual self. Some claim that the spiritual self is essentially all that there is of importance in life. Such people turn to their god in troubles no matter if the trouble is physical, mental, emotional, social, personal and so on. For others the spiritual self is illusory, Freud's pathologizing views regarding spirituahty illustrate this point. Here is essentially the view that science can address the same physical, mental, emotional, social and personal issues as spirituahty. These two views are the same in their exclusivity. Our purpose in this section is to consider Benner's (1988) integrative position which holds that the spiritual self is woven into the fabric of our psychological and physical being. The above two positions suggest duality's of body versus soul in the first view, and  21  science versus spirituality in the second. Our spiritual selves do not negate science and science does not negate our spiritual selves. Instead the science of our body, of our experience of the material world is invested with our spiritual selves. We are embodied spirits living in a paradox of experience. That a person is whole and not a collection of discrete physical or non-physical parts is widely discussed in the literature (Benner, 1988; Grimm, 1994; Mack, 1994; Tjeltveit, 1989; Westwood, 1995). In the helping professions the current trend is towards holistic treatment, recognizing the patient or client as a whole person rather than as a mental or physical condition. The following quote from Hall and Lindzey (1978), summarizes this view from the psychological literature but many similar discussions are found in the literature of the helping professions. Who is there in psychology today who is not a proponent of the main tenets of organismic theory that the whole is something greater than the sum of its parts, that what happens to a part happens to the whole, and that there are not separate components within the organism?... Who believes that there are isolated events, insulated processes, detached functions? Very few, if any, psychologists subscribe any longer to an atomistic viewpoint, (p 70-71) Nursing, physio-therapy and occupational-therapy, psychiatry, palliative care as well as more general areas of focus within medicine all present the same concept that treatment needs to recognize the person as a whole for maximum benefit to the patient or client (Aldridge, 1993; Peterson, 1987; Sims, 1994; Urbanowski & Vargo, 1994). Further, the spiritual self is central within the framework of a whole self. Lukoff and Turner (1992) from the psychiatry literature state that "the religious and spiritual dimensions of culture are among the most important factors that structure human experience, beliefs, values, behavior and illness patterns" (p. 673). Our spirituality is knit into every aspect of our being such that our spiritual convictions influence the way that we act, the way we perceive an issue and the context in which we live (Pedersen, 1995). Within the disciplines of mental illness then, the person is whole and the spiritual self operates as a central integrating factor. According to Jung (1933), the treatment of the spiritual self became developmentally the single most important issue for his clients. 22  Among my patients in the second half of life—that is over 35 years of age—there has not been a single one whose problems have not been in the last resort that of finding a religious outlook on life. It is safe to say that every one of them fell ill because he had lost that which the living religions of all ages have given to their followers, and none of them have been really healed who did not regain this religious outlook, (p. . 164) The spiritual self holds a pervasive influence in our makeup and is therefore relevant in the counseling context. In his paper entitled Faith: The fifth psychological need? Brent (1989) challenges the paradigm of Reality Therapy. His analysis looks primarily at the somewhat illogical fact that we have two almost identical brains and that the human experience of faith may arise from the fact of the different communication styles of each of our brains. The difficulty of communication between the two halves he suggests, creates the experience of unknowing therefore of infinite possibility and hence, it creates faith. He notes Gazzaniga's discussion of how humans, unlike animals, are not bound to the present but can reach beyond it and further; they can attempt to make sense out of chaos. To the end of perceiving a created order Gazzaniga notes that each of the Egyptians, the Mesopotamians, the Greeks and the ancient Israelites had one supreme god. Brent's concept of faith parallels our concept of the spiritual self in that both express that aspect of the self which reaches beyond present experiencing. While his work points to the connection between the physical and the spiritual within the framework of counseling, it remains theoretical and in need of empirical support. Given the comparatively small body of research which considers the spiritual self, the following studies are remarkable in their findings regarding the relationship of the physical and the spiritual. From his systematic analysis of the medical literature Levin (1993) has found that: Since the nineteenth century, over 250 published empirical studies have appeared in the epidemiologic and medical hterature in which one or more indicators of spirituaUty or religiousness, variously defined, have been statisticaUy associated in some way with particular health outcomes. Across this Uterature, studies have appeared which suggest that reUgion is salutary for cardiovascular disease,  23  hypertension, stroke, nearly every cancer site, colitis and enteritis, numerous health status indicators and in terms of both morbidity and mortality, (p. 54) Similarly Larson, Wood and Larson's (1993) systematic review of articles in the medical literature concerning spirituality reveals the salutary physical effects of the spiritual self. A brief summary of their findings indicates the following. 1. An analysis of 24 studies demonstrates no correlation of spirituahty with psychopathology. 2. Spiritual commitment has a positive correlation to mental health twice as often as a negative correlation. 3. Behavioral measures of spiritual commitment such as frequent prayer or church attendance are associated with positive mental health more so than are attitudinal measures. 4. Infrequent religious attendance should be regarded as a consistent risk factor for morbidity and mortality of various types. 5. Spirituahty is associated with lower blood pressure. 6. The beneficial associations of spirituahty on health status occurs 2.8 times as often as harmful associations or relationships. 7. They also note that spiritual or religious commitment has positive effects for drug abuse, suicide, delinquency. 8. Mortality studies have found that spiritual commitment can lengthen life, and this is true despite age, gender, marital status, education, income, race, health or previous hospitalization. 9. "In another study, an 8-10 year follow-up of 2,700 persons, only one social factor was found to lower mortality rates among women once other risk factors were controlled. That factor was increased attendance at rehgious services" (Larson et al., 1993, p.45). Larson et al.'s (1993) findings are so consistent that they conclude their presentation of their findings with the following statement: "Results are so consistently positive and so contrary to prevailing academic ideas that we beheve that the mental- and physical-health 24  professions may be on the verge of a transformation in perspective in the next few years" (p. 45). In summary, we are whole beings: spiritual, intellectual, emotional and physical. Our spiritual selves are central and interwoven with other aspects of our being. The implication of this is that treatment needs to consider the spiritual self as meaningful, powerful and essential to professional helping. Benner (1988) states that we cannot isolate spiritual and psychological problems by treating the latter nonspiritually or the former non-psychologically, "because the human soul is a psychospiritual continuum in which psychological stress, physical conditions and spiritual states are deeply inter-related" (Lovelace, 1979, 220). (p. 35)  Definition of the Spiritual Self It is necessary at this point to define the concept of the spiritual self. "Essential to such a definition is the recognition that, at the individual level, there typically exists a sense of one's nonphysical and transcendent innermost being which may be referred to as soul, spirit, essence, core or such like. This innermost being provides the person with a source of meaning and purpose in life, and a basis of self-evaluation" (Everts and Agee, 1993, p. 2). The spiritual self is that important part of the self that is characterized by mystery thus while defining it there is the contrary need to let it remain undefined. On the other hand, the definition must meet sufficient scientific rigors for meaningful research to occur. The definition of spirituality proposed by Chandler, Holden and Kolander (1992) is of great value as it has this unique dual property of being sufficiently broad to encompass diversity yet specific enough that it can be effectively used for research. According to their definition spirituaUty is "pertaining to the innate capacity to, and the tendency to seek to, transcend one's current locus of centricity, which transcendence involves increased knowledge and love" (p. 169). Using this definition they have addressed the foUowing seven issues: 1. SpirituaUty is a human capacity reaUzed to different degrees by different people. SpirituaUty is a universal human phenomena. 25  2. The tendency to spirituahty is on a continuum from repressed to a central preoccupation. Spiritual health occurs between these two extremes which are spiritual crises. 3. Seeking implies an individual motivation to create conditions whereby spiritual experiences may be more likely to occur. 4. They suggest a "locus of centricity" which is on a continuum of spiritual maturity. The continuum goes from ego-centered through to being centered within the body of humanity, the planet and ultimately the cosmos. 5. Their concept of transcend suggests "'moving beyond' in a direction of higher or broader scope" (Chandler et al., 1992, p. 169), this is conceptualized as a continuum. 6. Greater knowledge suggests a higher or broader world view. 7. A greater capacity to love "is meant to imply the paradoxical combination of benevolent acceptance of what is, and a motivation to bring about change that results in the greater good" (Chandler et al. p. 169). They find that this definition captures the diverse descriptors of spirit, soul, noncorporeahty, and sacredness. This definition is independent of religion, and incorporates both the relationship to a "higher power" as well as "no-thingness". The definition raises two issues that need to be addressed further. Firstly, items four to the end indicate spirituality's essential character of relationship which Chandler et al. (1992) fail to address in their discussion. Spirituahty inevitably means reaching beyond oneself which puts one into relationship. Using the construct of relationship described in Experiential Systemic Theory (Friesen, Grigg, and Newman, 1991), this relationship can be to a higher power, or to a no-thingness as they suggest. It can further be relationship to an experience, an idea, a place, a person, a community and so on. In fact the failure of Chandler et al. to address this in their discussion leaves one with the sense that spirituality is primarily a solo venture.  26  A second point that is not distinct in their discussion is the ordinariness of spirituality. For the purposes of this paper, the spiritual self is expressed in something as simple as the child's sense that "if only I could have that toy I'd be so happy". This is an expression of the child's inbuilt orientation to transcend their current locus of centricity. The spiritual self ranges from there, still within the boundaries of Chandler et al.'s (1992) definition to a person's much sought after spiritual experience. As Frank! (1988) suggests, the spiritual self is experienced in the process of living. The process of cleaning the house, going to the office, taking a holiday and so on rather than the events themselves, is infused with the spiritual self. The translation from spirituality as defined by Chandler et al. (1992) to the spiritual self which is the construct of this project is quite simple. Using Chandler et al.'s definition we add that one's experience of spirituality has to do with the self. In other words, my experience of spirituality has ultimately to do with who I am, my experience of the world, of relationships, my history, my perceptions and so on. This is not at all inconsistent with Chandler et al's work as demonstrated in their model of spirituality.  A Model of the Spiritual Self. The self can be seen as composed of component parts. Within systems theory, one may conceive of myriad parts which may be experienced within oneself (Schwartz and Gorman-Smith, 1990). For the purposes of this thesis we will use the model of the self devised by Chandler et al. (1992). According to their model, the self is divided into five major parts: the intellectual, physical, emotional, social and occupational selves. These five parts are divided further into two components; a personal component and a spiritual component. In their view, the personal and the spiritual are woven into all of the parts of the self. " Note ...that this model is interrelated and interactive with personal and spiritual components. Optimum wellness exists when each of these five dimensions has a balanced and developed potential in both the spiritual and personal realm" (p. 171).  27  Personal Component Spiritual Component  Figure 1. Model of the Self including the spiritual self Note. From "Counseling for Spiritual Wellness: Theory and Practice" by C. K. Chandler, J. M. Holden and C. A. Kolander, 1992, Journal of Counseling and Development, 71(2), p. 171.  Chandler et al. (1992) are unclear regarding the difference between the personal and spiritual components because they do not explicate the personal element. Assumedly the personal has to do with those aspects of self that are not spiritual, physical, occupational, intellectual, emotional or social yet are involved with all of these. The nature of the relationship between the spiritual and the personal is also unclear except that it is characterized by interrelatedness and interconnectedness. The failure to be clear about this distinction may reflect their primary concern to remain universal in their definition and  28  application. This limitation of definition simply leaves their model open to broader usage and interpretation, a necessary element in discussing the spiritual self.  Counseling is Value Laden Therapists in training and supervision are made cognizant of the importance of knowing their values and biases. The purpose of clarity is to exclude them from practice. Several authors discuss the fact that this ideal is unrealistic as counseling is a value-laden endeavor (Bergin, 1985; Jensen and Bergin, 1988; Strupp, 1980; Weiskopf-Joelson, 1980). Grimm (1994) presents an alternate discussion: A goal of effective treatment should be the integration of therapist spiritual and rehgious values with therapist epistemic values in order to accommodate the spiritual and rehgious needs of both client and counselor. Counselor spiritual and religious values can contribute to therapy, even when the therapist is engaged in a dialectic involving personal and epistemic values, (p. 154) These two views—that setting aside values is unrealistic, and that their inclusion may be desirable— are relevant because the incorporation of the spiritual self in helping is a deliberate introduction of a value-based approach to working. Research has shown that typically the spiritual self, is most often not included in training programs (Kelly, 1994). In a professional atmosphere of uncertainty regarding the spiritual self, the evolving professional does not have guidance or support to carefully consider either the imphcations of his or her spiritual values or the discerning use of them in counseling. As further background regarding the incorporation of the spiritual self in helping then, we need to consider the place of values, in particular those of the spiritual self in the counseling context. We begin our discussion by considering the hazards of not incorporating the spiritual self in helping. Arising from this discussion we will present the central importance of the counselor's rigorous understanding of his or her theory and view of human nature. Finally we will examine the strengths and then the advantages of incorporating the spiritual self in helping.  29  The Hazards of not Incorporating the Spiritual Self Several authors have noted the implausibility of leaving one's values at the door of the therapy office (Bergin, 1980; Strupp, 1980; Tjeltveit, 1989; Weiskopf-Joelson, 1980). This view is perhaps best summarized by Grimm (1994): In point of fact, psychotherapy is a values-ladened [sic] endeavor (Bergin, (1980); Beutler & Bergan, 1991; Kelly, 1990), even when the professional intent is to be values free or values neutral (Bergin, 1980; Beutler, 1979; Strupp, 1980; Weisskopf-Joelson, 1980). The clinician cannot avoid values and must practice within some epistemic values system (Browning & Peters, 1960). Indeed, values are embodied in each therapy session and in all research related to psychotherapy (Tjeltveit, 1989). Therapist values also play an important role in the formulation of clinical diagnoses (Weiskopf-Joelson, 1980). For example, Weisskopf-Joelson indicated that such diagnostic labels as 'psychotic' and 'schizophrenic' have been applied to individuals who have threatened those events or institutions that have been historically and, perhaps hysterically, valued by the therapeutic community (e.g., the American Revolution, slavery, heterosexuality). Therapist values are communicated to clients through therapists' concepts of mental health, approaches to psychotherapy, professional ethics (Tjeltveit, 1989), therapeutic methods, modeling behaviors, and therapeutic responses (Patterson, 1989). Values also impinge on the practice of psychotherapy because personal and sociocultural values help to determine theoretical orientation, the underlying assumptions of theoretical models, therapeutic methodology, and therapeutic goals. For instance, most Western psychotherapeutic models place value on freedom, autonomy, self-actualization, attempts to fulfill individual needs, and individual responsibility, whereas Eastern perspectives value uniformity, collective actualization, achievement of collective goals and collective responsibility (Corey, 1989). ( Grimm, 1994, p. 158) If we accept that counselor values are a significant part of the counseling process, the hazard of not incorporating our understanding of the spiritual self into the counseling relationship is that we are influencing the therapeutic process even though this is unethical, of limited use to the client and may disempower the client further. In the first place, we may be contributing to the division experienced by counselors between practice and theory. The practice of psychotherapy has always proven to be richer than the theories developed to explain and guide it....The relationship between client and therapist is a relationship between real human beings, between two whole persons. It therefore appropriately involves far more than technical operations. (Tjeltveit, 1989, p. 1) As the counseling relationship is the basis of change, the attempt to withhold a significant part of ourselves raises questions concerning trust, openness and genuineness.  30  Secondly, the problem of power in the counseling relationship arises. Pedersen (1995) rejects the idea that it is possible to ignore religious influence in counseling. "Counselors who choose to be noncommittal or 'objective are likely to fail because (1) 1  silence may be viewed as supporting a value position, (2) the counselor unintentionally communicates values to the client which may or may not be perceived accurately" (p. 10). The power imbalance is enhanced if the counselor does not recognize the influence of his or her values, and more pointedly his or her spiritual self, in the sensitive arena of the client's sense of need. The power imbalance is of course antithetical to the goals of counseling. Finally, it has been found that there is a larger representation of rehgious affiliation in the population at large than there is amongst helping professionals (Grimm, 1994). This fact in conjunction with the exclusion of the spiritual self in the counseling office suggests that we may not only miss what the client is attempting to explore, but we may impede or inappropriately influence his or her process. Watson (1994) in discussing spiritual emergency suggests that the creative and transformative potential inherent in spiritual emergency may be interrupted by psychotherapeutic orthodoxy. This is a portrait of chent needs and professional values in conflict. The Need to Reflect on Theoretical Models Perhaps the single most important factor arising from the above discussion of the hazards of not incorporating the spiritual self is the need to reflect on one's theoretical model. Dispensing with the ideal of leaving one's values at the door of the counseling office does not imply unleashed freedom of counselor values in the counseling office. Such action would be the equivalent of leaving values at the door as it would have the same counter-productive effects on the counseling relationship. On the contrary, a rigorous reflection on one's value orientation becomes more important. This is the case especially with regard to the spiritual self because of its central place in human experience. The importance of careful reflection on models of functioning is noted repeatedly in the literature (Grimm, 1994; Mack, 1994; Strupp, 1980; Weiskopf-Joelson, 1980).  _ 31  Tjeltveit's (1989) comments reflect the universal effect of theoretical models; his conclusions are similar to those found above. Models of human beings—explicit or implicit, rich or sparse, complex or simple, internally consistent or inconsistent, used deductively or analogically..., open to change or static—shape society, the actions of every human being, and every individual's worldview.... To fail to be aware of models is to risk being biased as a researcher and to risk ignoring key aspects of human experience and behavior. Moreover, it is to risk oppressing clients by imposing counselors' biased worldviews onto clients..., toriskconverting clients to therapist values inappropriately..., and to risk providing ineffective therapy because of an incomplete resolution of countertransference issues (p. 1). If the goal in counseling is to become redundant in the client's life, in other words, to somehow facilitate the client's independent functioning, we need to be attuned to the influence of our models in this direction. Further if our model incorporates the spiritual self which is a professional bias, we need to understand the implications of the model in counseling. Clearly, the need for reflection on one's model of human functioning is only increased once we acknowledge that values flow in the therapeutic conversation. In considering the creation of models which include a spiritual dimension, Grimm (1994) suggests that the therapist include religious and spiritual values because of their inevitability in counseling. He presents important considerations for the therapist regarding how to think about their own spiritual and religious values with respect to counseling. Because spiritual and religious values cannot be precluded from therapy and because these values might enhance the probability of positive therapeutic outcome with many clients, it is critical that therapists should be aware of their own related values, of their attitudinal and affective responses to particular spiritual and religious values, and of any unresolved conflicts pertaining to these values (p. 163). Grimm's comments point to the need for counselor awareness regarding the appropriate limits of theory and practice for the client's benefit. Recognizing the real limits of our professional skill is an area not given much consideration in counselor training, which may suggest again the highly personal journey needed for professional discernment. Discussion of appropriate limitations must consider the problem of indoctrination in models which would incorporate the spiritual self. It is commonly understood that mdoctrination of values or beliefs as initiated by the counselor, or encouraged by the client 32  (Rotz, Russell and Wright, 1993) is ill advised and unethical (Corey, 1989). Grimm (1994) discusses further reasons why spiritual indoctrination is unacceptable and suggests issues needing careful consideration by the counselor. His points are summarized as follows 1. Counselors have perhaps not fully evolved their own spiritual or rehgious values and are likely working with unresolved spiritual or religious conflicts. Grimm suggests that psychotherapists may in fact be in greater conflict than their chents because of their theoretical affiliation. Cohen's (1986) research supports this view. 2. It is questionable whether counseling is the appropriate setting for rehgious or spiritual teaching. 3. Spiritual and rehgious values orientations are not developed on the basis of one other person. 4. A viable spiritual life develops under multiple influences and it originates from within rather than from without. 5. The indoctrination of any value is inconsistent with most theoretical models. Grimm (1994) concludes "Because clients are generally more spiritually or religiously involved than are therapists, cross-cultural training and sensitivity would theoretically enhance the probability of positive therapeutic outcome" (p. 163). There are two observations to be made from Grimm's comments. Thefirstis the suggestion that the counselor may be in greater conflict than the chent spirituaUy. Strupp (1980) takes this comment further by suggesting a distinction between personal values and professional values. With respect to the spiritual self, it is possible to see that the counselor may hold personal behefs which remain personal in the professional context of the therapeutic relationship to the chent. While this description may suggest a type of sphtting, it can also be seen simply as integration and experience in one's work characterized perhaps by a broad capacity to entertain diversity and paradox in hfe. One illustration of this was the comments of a volunteer for the pilot interview in this study. On the one hand her  33  conversation was Rogerian in her adherence to unconditional positive regard. As an aside she later described an unshakable belief in the authority of Christ. In general this experience may or may not be conflictual for the counselor. In her case, it was her belief and trust in Christ that enabled her to attend freely to the client, she did not find this conflictual. A more legalistic Christian, or psychotherapist for that matter, may experience more conflict in this regard. The second observation to be made from Grimm's comments concerns his respect for the independence of the spiritual self. Grimm's discussion points to the boundary between counseling and spiritual guidance. It is not the role of the counselor to attend to his or her client's spiritual growth according to Grimm. The focus instead is on facilitating their development in the direction that they have indicated is meaningful to them. That the spiritual self is involved is inevitable according to Grimm, but that does not mean it is the focus of attention. As my pilot Co-researcher said of the spiritual self, "It is the core of who we are." and "It is kind of peripheral to counseling". This juxtaposition while it seems to suggest that counseling does not address the core of who we are, may in fact point again to the appropriate but evasive limitations of counseling. This uncertainty points us back to the need to reflect carefully on our models of human functioning. The Strengths of Incorporating the Spiritual Self We turn now to consider the meaningful strengths that the spiritual self brings to the practice of counseling. The following is an eclectic assembling of what is reported in the literature. To begin with we return to the work of Grimm (1994) who makes three major points summarizing the strength of incorporating the spiritual self in helping: 1. By taking a spiritual perspective one acknowledges that religious and spiritual realities exist and affect behavior. 2. Because therapeutic models are not value free, spiritual and religious values provide a moral and a universal frame of reference. This view is endorsed by Bergin  34  (1980) who has made the extraordinary attempt at identifying what these universal moral values might be. The suggestion is interesting, challenging and well beyond the scope of this paper to consider further. Grimm's comment is included here as an interesting implication for the reader's reflection. 3. Grimm argues finally that spiritual and rehgious values can provide a unique set of techniques for therapy, including intrapsychic techniques such as prayer and rituals and family or social system techniques such as group support. It can be seen that such techniques have already been incorporated in counseling. Chandler et al. (1992) for example talk about the use of meditation. Friesen, Grigg and Newman (1991) advocate the use of ritual and AA uses the construct of a Higher Power. These three points by Grimm encompass a great deal of thought and they convey an image of counseling in a much broader framework than is ordinarily considered. In their discussion of spirituality in counselor training, Everts and Agee (1993) discuss that spirituahty is related to chent adjustment in such diverse areas as intimacy, vocational decision making, locus of control, issues of birth and death and their attendant concerns. Everts and Agee highlight the necessity of cross-cultural training in incorporating the spiritual self as theyfindthat an individual's spiritual considerations are affirmed culturally with respect to world views and norms. In other words, in exploring a client's world view, their spiritual selves are operant. Their paper discusses the inclusion of spirituahty in counselor training and they conclude with a summary of the importance of spirituality for counselors. "Spirituahty contributes extensively to our understanding of client and counselor functioning and provides direction in the choice of intervention strategies at many points." (Everts and Agee, 1993, p. 9). Spirituality as they describe it, can play a significant part both in the development of pathology and in treatment. Their work demonstrates something of our earlier discussion regarding the centrahty of the spiritual self in human functioning and the related necessity and strength of incorporating it in practice.  35  Pedersen (1995) has focused on the religious expression of the spiritual self throughout the world. He suggests that, as counselors, we try to understand the endogenous or "inside-the person" sources of spiritual empowerment such as that found in religious ritual. His comments in this regard parallel Grimm's (1994) suggestion concerning the use of religious rituals. Pedersen points to the fact that counseling is a healing art in other cultures, and that it has frequently incorporated a distinctly religious aspect: Studying these alternatives to talk therapy is useful not only because some remnants of those modes may survive in our own deep unconscious understanding but also because some of these primal examples may have retained insights that more industrialized society has forgotten, (p. 4) Again we see the implication that counseling can go further in its understanding of human experience because human experience goes further than counseling theory. Pedersen (1995) goes on to discuss the importance of understanding a client's religious development and illustrates using the Toba Batak of North Sumatra in Indonesia. He outlines the influence of their religious background on their movement into Westernization. He concludes with the comment that "while counseling often seeks the elimination of pain and suffering, the primal [endogenous] alternative...goes beyond suffering to the attainment of inner freedom and the experience of one's own divinity" (p. 26). His comments are reminiscent of Aldridge's (1993) discussion of health and suffering, and both of these challenge current reductionistic theories of change and healing. In summary, the strength of incorporating the spiritual self in counseling is related primarily to the potential for broadening our understanding of human experience. The result of this increased breadth is a more enriched theory of human functioning and of practice. Perhaps it also has the potential of enriching the therapeutic exchange, as counselors can attend to the wisdom of their spiritual selves both privately and professionally. Further, the therapeutic exchange can be enriched through sensitivity to the broad influence of the spiritual self for the counselor and the client.  36  The Advantages of Incorporating the Spiritual Self This section concludes with a very brief discussion of the advantages of mcorporating the spiritual self in practice. Mack (1994) stresses that a more integrated reflection on human nature can increase consistency between therapists' theory and their actions in research and therapy. She and Tjeltveit (1989) claim further that the integration of a spiritual perspective will reduce the incidence of countertransference by causing professionals to reflect personally. "The honesty pertaining to the spiritual viewpoints of the therapist suggests potential to aid practitioners in projections that may impede both professional awareness and subsequent client growth" (Mack, 1994, p. 26). The advantage of incorporating the spiritual self is that it serves both the counselor and the chent in their personal growth and development. The counselor is challenged to enrich his or her work through awareness and attention to his or her spiritual self. The chent is hopefully served better in allowing this important element of their experiencing its central place in their process of change.  Theoretical Conceptualizations of the Spiritual Self In general, the schools of psychoanalysis and existentialism have been the most articulate in depicting the spiritual self in theory. Articulating a depth of human experiencing is not foreign to these schools. It is no surprise then that the selected theorists are from these two schools. Numerous other theories though articulate to a lesser extent on the topic of the spiritual self, have nevertheless addressed the topic. Notably in this paper there is the work of the Reality Therapist Brent (1989) and the work of numerous Systems Therapists (Berenson, 1990; Holmes, 1994), the Psychiatrist Sims (1994), Cross Cultural Theorist Pedersen (1995) and others. Often the work of theorists has also been adapted to examine the spiritual self. The work of Rogers (Fuller, 1982), Piaget, Erikson, and Kohlberg (Pedersen, 1995) have all been in some way re-worked to consider the spiritual self. Our present examination includes one such example with Helminiak's (1988)  37  adaptation of the work of Fromm. That some approaches do not specifically articulate the spiritual self may be more an indication of the theoretical approach than a repudiation of the spiritual self. We note for example that systems theorists are well represented under the following subsection examining clinical experience of the spiritual self. This is perhaps an indication of the preference in systems theory to look at pattern rather than content of relationships. On the other hand, it may also be simply an issue of neglect (Berenson, 1990, Gutsche, 1994). This is a preliminary effort at presenting theory which has depicted the spiritual self. The potential of this section is sufficiently large to warrant it's own body of research. We have two purposes however. First of all we will see that the spiritual self has frequently been worked into theories of helping. Frequency supports the contention that the spiritual self is common in human experience and is not simply relegated to religion or spiritual experiences. Further, frequency of representation makes it possible to understand that the integration of the spiritual self in helping has been a consideration through the history of counseling. Secondly, comparing and contrasting several theoretical conceptualizations demonstrates the diverse means of integrating the spiritual self and it raises some of the issues for consideration in creating a working model for helping professionals. There are several commonalties that arise in the following discussions. A l l of the theories hold that the spiritual self is an innate human property, and all of them express some form of relationship as underlying the spiritual self. Jung's construction of the spiritual self is the relationship of the conscious and the unconscious. Fromm sees the spiritual self arising in the relationship of the physical and the mental selves. More classically, Benner endorses meaningful relationships to others and to a god. For Kierkegaard it is the relationship of the self to the self and to God that forms the basis of integration. Frankl is the most ambiguous in his depiction of the spiritual self, it is the relationship to something which is beyond the self. Finally, for Yalom the spiritual self is expressed in relationship to a cause, a person or a goal.  38  The diversity of the spiritual self is also represented in these theoretical orientations that rangefromdeeply intra-personal to more generalized views, and from rehgious views to evolutionary and hedonistic views. Some of the approaches hold that the spiritual self is expressed in searching or growth while some hold that it is expressed in surrender and a sense of immanence. The question of the practitioner's position of relativism versus adherence to a search for truth arises particularly in Fromm's challenge of Jung's work. The question of whether care is in essence spiritual or psychological also arises and there is some consideration of the relationship between these two. Finally, a challenge is posed to our model of the spiritual self which divides the personal and the spiritual. Some of the theorists, Kierkegaard most notably, state that humans are spiritual beings. This position raises the theoretical question regarding the line between the spiritual and the personal expressed in Chandler et al.'s (1992) model of spirituality. What follows is a presentation of the conceptualizations of the spiritual self as construed by the six theorists; Jung, Fromm, Benner, Kierkegaard, Frankl and Yalom. The discussions are focused exclusively on outlining the view of the spiritual self and presenting the issues that one raises in relation to others. Jung Jung viewed the spiritual self as central for healthy human functioning. Some have argued that this was in reaction to Freud's outright rejection of the spiritual dimension of human experience (Helminiak, 1988). Regardless of that contention, he claimed that "recovery of the soul was essential for both the individual and Western society " ( Elkins, 1995, p. 79). Jung's work has had pervasive effects in modern social and religious views of spirituahty (Satinover, 1994).  A central element of Jung's theory; individuation,  reflects our working concept of the spiritual self: The primary concept of Jung's view is that of individuation : the life process of achieving wholeness through synthesis of conscious and unconscious aspects of self (Corsini & Wedding, 1989). Jung labeled this process of individuation as rehgious in nature, characterized by the human capacity to submit individual egowill to the will of God through movementfromthe ego as center of personality to the genuine self as center...The self, therefore, is considered the central mechanism 39  involved in the spirituality of the individual and is understood as the God-image within the psyche of each individual. Hence, according to Jung, both psychology and spiritual health depend on an open relationship between conscious and unconscious forces in personality. This open relationship, which is fundamental for the Jungian process of personality integration, is the criterion in discerning genuine spirituaUty. (Mack, 1994, p. 16-17) For Jung, personality integration equals spirituality. The process of individuation is a spiritual process of corning to the genuine central self, the god-image. This genuine self is holy in Jung's view. Individuation then, reflects the human orientation to transcendence indicated in our definition of the spiritual self: "pertaining to the innate capacity to, and the tendency to seek to, transcend one's current locus of centricity, which transcendence involves increased knowledge and love" (Chandler, Holden and Kolander, 1992, p. 169). Jung agrees that the spiritual self is innate: "Jung labeUed religiosity as an instinctual aspect of human functioning, viewing each individual's spiritual longings as a creation from the ancestral unconscious (Jung, 1933, 1934)" (Mack, 1994, p. 16). As mentioned earlier, Jung noted that among his patients over 35 years of age every one of them had to make some form of spiritual resolution in order for healing to occur (Jung, 1933). The effect of his view of the centrality of the spiritual self was that Jung integrated spiritual belief within the context of counseling, not rejecting it as an expression of neuroses as Freud had done. Jung's work is Uberating in faciUtating the possibiUty of connection among spiritual perspectives by acknowledging the universal nature of the spiritual self. Further, he initiated a meaningful incorporation of the spiritual self in the counseling context. In this professional sense Jung's work was visionary in an age when the tide of empiricism and positivism could not accommodate spirituaUty. Fromm In an effort to convey an alternative universal understanding of the spiritual self in helping, Helminiak (1988) makes a careful review of Erich Fromm's work. Helminiak's argument rests on three legs by which he conveys the centrality of the spiritual self in Fromm's view. 40  In thefirstplace Fromm argues that humanity has evolved from the animal species to become distinct in the ability to adapt due to our powers of reason, self-awareness and imagination. Fromm argues that this evolution from animal to human leaves us with a fundamental dichotomy of the limitations of our physical nature versus the seemingly unlimited capacity of our minds in self-awareness, reason and imagination. The dichotomy leaves humans in the unique position of needing to "determine their own life's conditions on a sociobiological and historical basis" (Helminiak, 1988, p. 224). This dichotomy, which is closely related to reason, forms the second element of Helminiak's analysis. As a result of the dichotomy humans are driven to "resolve contradictions inherent in the human situation. Existential needs demand the construction of frames of orientation and devotion—religious systems. Within these arise the passions and strivings that explain so much of human behavior" (Helminiak, 1988, p. 224). Note that Fromm is describing a universal human phenomenon of striving to transcend the inbuilt dichotomy of experience. One illustrative element of this striving is the existential need to understand human experience. In this universal human orientation of striving to transcend we see Fromm's evolutionary construction of the spiritual self in contrast to Jung's ancestral and ego-based natural spirituality. Finally, Helminiak (1988) points to Fromm's humanist views that virtue, love and ethical behavior are emergent in human behavior. Choices that are good, are good for the individual, choices for evil are counter to the best interests of human experiencing. Good, bad and so on are not transcendent but are immanent in human experience. Fromm's concept of health then, briefly described in this construction of human choosing, is wholly related to the concept of the spiritual self. In other words, choice— which rests on the basis of belief, hope, reason, imagination, in general one's ability to perceive beyond present experiencing as a result of the spiritual self— is the basis of healthy and unhealthy human functioning.  41  In summary then, Fromm's work illustrates a construction of the spiritual self in two ways. First of all, because of the inherent dichotomy of being human, we strive to resolve and understand our human experience thus illustrating our human orientation to transcendence or the spiritual self. Secondly, Fromm's construction of health based on choice also underlines the centrality of the spiritual self in his theory because of the transcendent properties of choice making. Fromm refers to his approach as philosophico-positivistic, and from this vantagepoint he offers valid criticisms of both the philosophy of religions and the positivism of psychology incorporating thus the richness of each within the framework of being "for himself (Helminiak-, 1988, p. 228). His view is summarized in his vision of psychology's challenge to embrace the wholeness of being human in the process of healing. The progress of psychology lies not in the direction of divorcing an alleged 'natural' from an alleged spiritual' realm and of focusing attention on the former, but in the great tradition of humanistic ethics which looked at man in his physicospiritual totality, believing that man's aim is to be for himself and that the condition for attaining this goal is that man be/or himself, (as cited in Helminiak, 1988, p. 228) 1  Fromm was critical of the limitations which he perceived that Jung's relativism imposed on his development of theory. According to Fromm, Jung recognized that psychology and psychotherapy are bound up with the philosophical and moral problems of man. But while this recognition is exceedingly important in itself, Jung's philosophical orientation led only to a reaction against Freud and not to a philosophically oriented psychology going beyond Freud. To Jung "the unconscious" and the myth have become new sources of revelation, supposed to be superior to rational thought just because of their nonrational origin....In his eclectic admiration for any religion Jung has relinquished a search for the truth in his theory. Any system, if it is only nonrational, any myth or symbol, to him is of equal value. He is a relativist with regard to religion—the negative but not the opposite of rational relativism which he so ardently combats, (as cited in Helminiak, 1988, p. 229) Fromm rejects Jung's relativism on the grounds that he does not see humans as infinitely malleable for three reasons. In the first place " the human being would be only a puppet of social arrangements and not—as he has proved to be in history—an agent whose intrinsic properties react strenuously against the powerful pressure of unfavorable social and cultural patterns" (as cited in Helminiak, p. 226). Secondly, Fromm felt that uniqueness would be 42  non-existent as humans would bear only the stamp of social patterns. Comparative sociology would be the sole human science. Finally, there would be no history. Social conditioning would eliminate the difference between humans and animals, history would be non-existent as diversity of experience would not exist. In the above quote Fromm raises the issue of the paradoxical relationship of truth and theory. Fromm comments that Jung abandoned " a search for the truth in ...theory" (as cited in Helminiak, 1988, p. 229) by wholeheartedly accepting relativism. Fromm sees relativism as a major limitation of Jung's work. Fromm's work suggests that in replacing a pursuit of truth with relativism Jung risks undermining uniqueness, a central element of healing. The incorporation of truth in theory building suggests a deep integration of the spiritual self within theory and practice. Here the spiritual self and the professional self are vitally linked for meaningful work to transpire. One can surmise that for Fromm, the spiritual self is a vital link for healing work. Benner Benner's (1988) work rehes heavily on Jung but with modifications whereby he addresses Fromm's criticism of Jung's relativism and expresses his own Christian view. Benner accepts Jung's concept of natural spirituality but further refines it to incorporate religious and Christian spirituality as well. In this way he addresses Fromm's preference for rrum-seeking as opposed to Jung's relativism. The three elements of natural, rehgious and Christian spirituality are illustrated as overlapping in the following manner:  43  Figure 2. Benner's Model of Spirituality Note. From Psychotherapy and the Spiritual Quest (p. 105), by D. Benner, 1988, Grand Rapids, MI: Baker Book House. Benner (1988) rejects Jung's notion of God as the center of being, he suggests instead that this center of being is closely connected to God. The center of the soul is not God, but it is so intimately grounded in God that it can and sometimes is mistaken for God himself. The center is the created ground of being grounded in God's Uncreated Being....This most profound and sacred depth of the soul is the dwelling place of God. It is in this divine center that we are made in his likeness. Nothing can fill or satisfy this center except God himself. At this center God is more real than man is. (as cited in Benner, 1988, p. 71) The significance of the difference of these views is of course arguable. Benner however shares Jung's view that the process of counseling at best points one inwards in a deepening reflection on the spiritual self. Benner (1988) distinguishes himself from both Jung and Fromm by embracing the view that the spiritual self is characterized not so much by searching as by surrender. This view is seen in contemplative psychology which describes spirituality as "the willingness and courage to open oneself to mystery" (p.69). Along these lines May defines spirituaUty as "the human being's capacity to practice wiUingness versus wiUfulness" (as cited in  44  Mack, 1994, p. 17). It may be argued that this discrepancy points more to the issue of spiritual discipline rather than the spiritual self. If one considers the client who has suffered a loss however, (as loss is an almost universal characteristic of people in pain) it is clear that at some level surrender, or an attitude of willingness become important ingredients in reaching beyond present experiencing. Benner (1988) describes a complex relationship between psychology and the spiritual self. The argument is reminiscent of Aristotle's distinction between formal and essential causes: Psychological factors may be said to refer to the form or shape of the psyche—to the knowledge, talents, and preferences which define a personality's boundaries. But psychological issues have no bearing on the material or essence from which the psyche is made. This is an issue of spirit. The spirit is the basis of the possibility of identity, the ontological ground from which inheritance, experience, and culture develop personality. Furthermore, because spirit is thought to be external it is not limited to the natural world. It is the spirit's capacity for connecting to supernatural sources of power that allows the possibility of changes not only in the form but also in the very essence of personhood. (Aristotle, n.d./1970, Book II Chap. 3, as cited in Harrison, 1988, p. 317) For Benner, the spiritual self is in some sense greater, more complex, more replete with mystery than what is captured in psychological knowledge. This does not render psychology meaningless, but a valuable tool in understanding the workings of the spiritual self. He states that communication with God occurs in the ordinary channels known in psychology. If the communication is not rational, Benner suggests that it could be intuitive, emotional or even unconscious. Benner argues that God could but does not use unique avenues of communication. Instead God communicates using the avenues of communication God has created; the senses, imagination, reason, self awareness, circumstance, and so on. His comments are reminiscent of Frankl's (1984) comment to the effect that if there is a God he answers prayer through known avenues of experience. Benner (1988) also believes that psychology is infiltrated by spiritual truth: All psychological structures and mechanisms also have a spiritual basis...The use of the will, emotions, learning imagination, creativity, or the intellect is a spiritual matter. This does not make them spiritual mechanisms or structures. There are no such things. The mechanisms of the spiritual life are psychological. But  45  psychological mechanisms inevitably have direction, and that direction comes from the spiritual basis of psychic life. (Benner, 1988, p. 116) Benner is stating both that psychological mechanisms come from the spiritual self and that a person's psychology is the means whereby spiritual reality is communicated. Benner refers to this intersection of the spiritual and the psychological as a model of psychospiritual unity. The model has implications for both psychological and spiritual issues. For Benner, psychological wholeness includes meaningful engagement with others, the integration of the conscious and unconscious, and self transcendence "that involves surrender to and service of a larger cause or being" (Benner, 1988, p. 130). Psychological problems block spiritual growth by enhancing pre-occupation with self and thus deadening spiritual sensitivity. "This narcissistic self-encapsulation is the essence of both sin and psychopathology" (as cited in Benner, 1988, p. 124). On the other hand spiritual growth does not automatically follow from psychological growth. "It is undoubtedly quite common for psychotherapy, as it is usually practiced, to lead to psychological growth and not be foUowed by spiritual growth" (Benner, 1989, p. 124). This is a valuable consideration for the helping professional integrating the spiritual self in their work. Benner is proposing that while the work involves the re-integration of the client's spiritual self for healthy functioning, the responsibility remains that of psychological care with the real but not necessary possibility of spiritual growth. Our concern is not primarily with spiritual growth, but with psychological well-functioning. Kierkegaard Kierkegaard is an unlikely theorist to include here because his work is not often a primary source in helping professions. His work is included briefly however because it underhes the development of much existential theory. Further, his view of the spiritual self represents an extreme conceptualization, thus his work poses a challenge to the research definition and model (Chandler, Holden and Kolander, 1992) of the spiritual self. His work suggests that the self is neither divided into the personal and the spiritual nor is it a 46  separate aspect of self. It's value in this context then is to maintain an open perspective on what the incorporation of the spiritual self in helping may entail. Kierkegaard holds an unequivocal view that humans are spiritual beings, to be human is to be spiritual. Man is spirit. But what is spirit? Spirit is the self. But what is the self? The self is a relation which relates itself to its own self, or it is that in the relation (which accounts for it) that the relation relates itself to its own self; the self is not the relation but (consists in the fact) that the relation relates itself to its own self. Man is a synthesis of the infinite and the finite, of the temporal and the eternal, of freedom and necessity, in short it is a synthesis. A synthesis is a relation between two factors. (Kierkegaard, 1849/1954, p. 146) He goes further, asserting that "each individual can only discover truth of self by becoming grounded in something external to the self, specifically God" (1849/1954, p. 18). For Kierkegaard to be a self is spiritual in nature with irifinite implications. Health has to do with finding relationship to God. One can sidestep this potential for health by either refusing to acknowledge one's duality and therefore refusing to be a self, or by embracing the duality and rejecting God's primacy. Both of these result in false selves. The true self according to Kierkegaard is found only in surrender to God. Kierkegaard's construction of the spiritual self is reminiscent of Jung's view of the genuine self in that both describe the relationship of the self to the self. Jung however layers psychological factors into his construct of human functioning. Kierkegaard ismore of a purist in this regard. Likewise, the property of duality in Kierkegaard's thought is similar to Fromm's work. While Fromm's duality of the self has an evolutionary base however, Kierkegaard's view is based on the primacy of spirituality. Kierkegaard's strong view of the centrality of God in healthy human functioning poses perhaps the clearest challenge to the helping professional who incorporates the spiritual self in their work. The implication of his work is that psychological practice has little relevance unless it is specifically practiced in relation to the exploration of the person's experience of their spiritual selves. Fromm's emphasis on truth-seeking has similar implications however. Jung and Benner also are not necessarily in disagreement with  47  Kierkegaard's view. From a different vantage point, their assertions that the spiritual self is an almost inevitable variable in the counseling process reflects on the responsibility of the helping professional's consistent incorporation of the spiritual self into their work. Frankl Rather than focusing on elements of human experience, Frankl (1988) focuses on unity of being. In Frankl's view to extract a spiritual self from human experiencing is reductionistic and distorts a more holistic appreciation of human experiencing. Frankl's discussion of self transcendence however parallels our definition of the spiritual self. Our discussion is centered on his related concept of self transcendence (Frankl, 1969, 1988). By adherence to our definition of the spiritual self it is possible to see that Frankl too presents an understanding of the spiritual self in human functioning. Self transcendence is not described in discrete terms in Frankl's (1969, 1988) work, rather it is phenomenologically experienced and it is expressed in the tension between the self and Frankl's construct of meaning. To present Frankl's work related to the spiritual self involves the isolation of disparate elements to approximate a concrete description of self transcendence and the spiritual self. This is counter to Frankl's (1988) expressed intentions but aids in simplicity. We will describe the spiritual self in Frankl's work then with reference to three points; growth, transcending the self, and the content of living. Thefirsttwo are conveyed in the research definition of the spiritual self from Chandler, Holden and Kolander (1992). The last one introduces a description of spiritual experience which we have not encountered thus far and adds to our consideration of the spiritual self. With respect to growth, Frankl (1988) disputes the "homeostasis principle" of many approaches to care. The homeostasis principle, he argues, makes the erroneous assumption that the goal of aiding the client is to regain a level of equihbrium. For Frankl equihbrium is not reflective of human experience, instead he sees experience in the tension between self and meaning which is related to a continual growth process. As stated above,  48  for Frankl, self transcendence is expressed in the tension between the self and meaning. A reasonable connection to make then is that for Frankl, self transcendence is related to growth. In the following quote Frankl describes two qualities of the spiritual self as suggested in our definition; it is innate and it has to do with reaching beyond the self: It is a constitutive characteristic of being human that it always points, and is directed, to something other than itself. It is, therefore a severe and grave misinterpretation of man to deal with him as if he were a closed system. Actually, being human profoundly means to be open to the world, a world, that is, which is replete with other beings to encounter and with meanings to fulfill. (Frankl, 1969, p. 97) The idea of being open to the world is more than an evolutionary view of man as ape. Frankl rephrases part of the above quotation: "It is a characteristic constituent of human existence to break through the barriers of the environment of the species homo sapiens" (Frankl, 1988, p. 31). He is pointing to the fact that it is our nature to reach beyond our physical limitations in the direction of understanding, relationships, opportunities, in short, experiences of meaning which may or may not have to do with a spiritual being. Finally, Frankl discusses that self transcendence is in the content not the form of living. Stating it in the negative Frankl notes: "It is obvious that dealing with the uniform forms of experiences rather than with their different contents presupposes that the selftranscendent quality of human existence has been shut out" (p. 39). In other words, to say '1 climbed a mountain" does not describe self-transcendence. The content or process of that experience however, involves the experience of self-transcendence. To summarize we begin by referring again to Chandler, Holden and Kolander's (1992) definition of the spiritual self: 'pertaining to the innate capacity to, and the tendency to seek to, transcend one's current locus of centricity, which transcendence involves increased knowledge and love" (p. 169). The review of Frankl's discussion of self transcendence parallels our definition in that Frankl presents an innate capacity to transcend immediate experiencing in the direction of growth. Frankl's discussion regarding form and content is a valuable depiction of the ordinariness of the spiritual self. 49  Frankl's perspective, like Kierkegaard's challenges the duality of our model of spirituality in its preference for a holistic view. Further, the dissection of his discussion of self transcendence may undermine his express intentions and certainly it is difficult to extract a succinct description of the spiritual self. Our purpose however, has not been to challenge his theoretical construction, but to see that our present understanding of the spiritual self is represented in his work. This has been accomplished by reviewing his work from within the framework of our definition and discussion of the spiritual self. Frankl's holism, opens the possibihty of a universal professional integration of the spiritual self in work. In a sense he incorporates both Jung's relativism whereby all spiritual perspectives are valued, and Fromm's trum-seekrng whereby the pursuit of truth is of importance at an individual level. Yalom We have considered spiritualistic, humanistic, rehgious, and holistic constructs of the spiritual self. Yalom (1982) presents what is best described as a secular view of the spiritual self. He uses Frankl's constructs making possible the same interpretations of the spiritual self as discussed above. Yalom illustrates the tension between the self and meaning using non-spiritualized expressions of the spiritual self. His discussion is included here because he makes a specific adaptation of Frankl's work in finding meaning in secular experience. This is a much more earthy expression of the spiritual self than we have seen in any of the previous theorists. Yalom's (1982) discussion of the spiritual self occurs in " the secular activities that provide human beings with a sense of hfe purpose. They seem right; they seem good; they are mtrinsically satisfying and need not be justified on the basis of any other motivation" (Yalom, 1982, p. 92). His intention is to consider the viewpoint of secular people who are not inspired by any form of spiritual influence. Yalom (1982) lists a number of potential expressions of the spiritual self in keeping with a secular view. Leaving the world a better place to hve in through serving others and  50  working for charity covers a considerable amount of activity that expresses the spiritual self in Yalom's view. He notes for example how dying patients who engage this manner of living, live and die more fully than others. He cites Will Durant who suggests the necessity of reaching beyond the self. Join a whole, work for it with all your body and mind. The meaning of life lies in the chance it gives us to produce, or to contribute to something greater than ourselves. It need not be a family (although that is the direct and broadest road which nature in her blind wisdom has provided for even the simplest soul); it can be any group that can call out all the latent nobility of the individual, and give him a cause to work for that shall not be shattered by his death" Many kinds of cause may suffice: the family, the state, a political or religious cause, secular religions like communism and fascism, a scientific venture. But the important thing as Durant states is that 'it must, if it is to give life meaning, lift the individual out of himself, and make him a cooperating part of the vaster scheme, (as cited in Yalom, 1982, p. 95) Yalom also includes creativity, self actualization, self transcendence, altruism, and hedonism as important sources of meaning for the nurturance of the spiritual self. Finally Yalom (1982) discusses the hazard of focusing on the self that is related to a non-transcendent attitude. The dangers of nontranscendent posture are particularly evident in interpersonal relationships. The more one focuses on oneself for example, in sexual relationships, the less is one's ultimate satisfaction. If one watches oneself, is concerned primarily with one's own arousal and release, one is likely to suffer sexual dysfunction. (Yalom, 1982, p. 100) Note that the dynamic of relationship is used to demonstrate the cost of neglecting the spiritual self. As demonstrated by Yalom, the spiritual self has importance in human functioning even in venues which reject altogether any objective aside from immediate personal meaning. With reference to our definition, Yalom's work does not overtly assume that the spiritual self is an innate tendency, it seems to imply however that it is an innate necessity related to a fulfilled experience of living. He is not articulate on this point but once the question of mffillment in living is raised one must consider whether he is not suggesting that the potential for expression in the spiritual self is universal but perhaps in some 51  situations dormant. His work demonstrates agreement with the concept of reaching beyond the self in relationship to a cause, person or goal is of value. Increased knowledge or love as a result of this extension of the self is a realization that he has both recognized and experienced. Conclusion In conclusion, we have seen that diverse theories can support our definition of the spiritual self. This finding of commonality despite diversity is meaningful with regard to our present attempt to find how the spiritual self is incorporated in practice. Apparently numerous theorists have found the expression of the spiritual self in their work meaningful in constructing theories of helping and change. Meaningful lines of diversity have also been found in the construction of theory whereby issues such as; relativism, truth-seeking or holism; searching or surrender; the question of the spiritual aspect of care; and the nature of self whether divided or whole are all addressed. Clinical Applications of the Spiritual Self Diversity also characterizes the following sampling of literature which considers the spiritual self in helping. The observations from this literature are not based on research. This review is included because of the lack of research and because it conveys clinical experience of the spiritual self in helping. The discussion is broken into two major categories. The first considers models of integration of the spiritual self. The second looks at case studies involving clients or counselors. We note that much of this literature points exclusively to religious experience. In the first section for example, only Westwood (1995) and Chandler Holden and Kolander (1992) frame the spiritual self as part of a holistic view of human functioning. The remainder adopt an exclusively religious view of spirituaUty. This is an illustration of the bias of the construct of spirituality found in the Uterature. As a guiding assumption of this paper is that the spiritual self is innate however, factors discussed in relation to it are  52  considered to a greater or lesser extent also universal. A fundamentalist Christian and a fundamentalist vegetarian may express their spiritual selves in comparable ways. It is the responsibility of our readers then to consider in what way the authors' religious frameworks can be broadened to consider human spirituality as the topic of discussion. Models of Integration Two elements are common in the following papers which present models of integration of the spiritual self. First of all there is the problem for the clinician of "taking on God" in the mind of the client. That is, in the process of challenging irrational thoughts or using reframes the client can misconstrue the discussion as a challenge to the client's belief system. In short the issue becomes one of who has greater authority in the mind of the chent; the clinician or god. The risk of course is to the therapeutic relationship and the possible repudiation of the therapeutic process by the chent. The second common consideration of these discussions is the healthy functioning of the chent's spiritual self. Spilka (1986) suggests five different modes of the spiritual self in relation to psychological dysfunction. Religion, or for our purposes the spiritual self may 1). allow or sponsor the expression of abnormality; 2). act as a control or socializing force to suppress pathology; 3). function as a refuge, protection or haven from life's stresses; 4). provide constructive directions for more effective interactions with others; and 5). operate as a stressor to exacerbate existing weaknesses and problems, (p. 94) Spilka suggests that the traditional view in psychology has emphasized the dysfunction of religion and ignored the advantages of it. The following discussions challenge this perspective by looking more roundly for indications of health or dysfunction in the client's spiritual life as suggested by Spilka. The following models of integration demonstrate diverse approaches moving from specific questions to a more interpersonal style of assessment. The information is not contradictory, rather, in combination it contributes to a background understanding of the dimensions necessary for assessment of the client's experience of their spiritual self.  53  Peteet(1994). Peteet, (1994) offers a 4 point clinical approach to clients who present with spiritual and religious problems: 1. Acknowledging the problem but focusing exclusively on its psychological dimension. 2. Clarifying and suggesting resources for addressing religious or spiritual problems elsewhere. 3. Addressing the problem indirectly by using the Patient's spiritual perspective to foster greater integration of his spiritual and emotional life. 4. Addressing the spiritual problem directly within the framework of treatment through use of shared religious or spiritual orientation. The clinician using this model sorts among the four elements to find a suitable course of treatment. The first two points raise the not insignificant issues of careful attention to the client's needs and an increased risk of rejecting a vulnerable client. The third point seems the most useful of the four as the goal is greater integration of the spiritual self. The use of an indirect approach however seems questionable. The fourth point, treatment through shared religious orientation suggests a possible conflict for the professional with respect to taking a therapeutic stance. In general this model seems oversimplified and the spiritual self is not seen as integrated in functioning. Worthington (1989). Worthington (1989) outlines a framework for interviewing: 1. How formal should the assessment be? 2. To what degree is the content of a person's faith to be assessed versus the process of "faithing"? 3. How is religion involved in the life of the client? 4. How mature is the client in his or her religious life as well as in his or her cognitive moral and socioemotional life?  54  5. To what degree if any, is the chent's religion related to the diagnosis? 6. To what degree, if any, is the client's religion involved in the etiology of the problem? 7. Is religion part of the client's identity? 8. Is the counselor competent to deal with a client's rehgious and spiritual concerns (as cited in Pedersen, 1995). This framework is helpful in several ways. It highlights the degree of focus a chent places on their spiritual hves and provides a valuable means of exploring the relationship of their spiritual self to their presenting issues. It also identifies potential areas for further investigation. The final question points to the important selfreflection of the helping professional in knowing their limitations and being equipped to refer the chent if necessary. On the other hand, this cognitive assessment may err in failing to allow the chent to adequately represent their spiritual lives. Further, the focus on religion may preclude a more global exploration of their spiritual experience. Peterson (1987). Peterson's (1987) work is focused on the need for nurses to breakfromthe influence of psychiatry and the tendency to pathologize clients' spirituality. She assesses the chent's spiritual self in three areas and goes further than the above clinicians by employing spirituahty in a healing process. 1. Peterson initially observes the Patient's environment; including available religious materials, social and family environment, physical functioning, rehgious affiliation and needs. 2. Rehgious practices are also considered in the assessment; including what they are, their meaning to the chent and their relationship to the present distress, as well as their relationship to hope and a sense of integrity. 3. Finally she explores the patient's sense of meaning and purpose; including a means of forgiveness, a source of love and relatedness, management of guilt, and the chent's ability to feel loved, valued and respected. Peterson uses basic counseling skills.  55  She suggests visuahzation using the client's religious imagery, the use of religious music and meditation with religious verses which are meaningful to the chent. She advocates referral and consultation with spiritual guides who are also working with a particular client or patient. This model has the advantage of being more honoring of the client's expression of spirituahty than the previous examples. It also focuses on the potential health of the client's spiritual life and emphasizes empathic attending to the chent's spiritual self. Peterson is innovative in her attention to the client's physical space. Peterson's endorsement of interdisciplinary work for the purpose of both referral and consultation is also well considered for the benefit of the client. Peterson's work celebrates the commonness of the spiritual self rather than holding the professional in a falsely objectified and clinical posture. She also incorporates the spiritual self in healing. Clinebell (1972). Clinebell's (as cited in Peterson, 1987) model of spiritual wellness, though unwieldy for practical purposes is included here because of the strength of insight which it offers regarding the health of the spiritual self. His formulation is based on rehgious thought and practice but is easily adapted to consider spiritual issues. A series of reflective questions begin with the words "Does one's religious thought and practice....". A n inclusive preface however highlights the strength of the model in the present context. Hence; 1. Does one's spiritual life build bridges or barriers between people? 2. Does one's spiritual life strengthen or weaken a basic sense of trust and relatedness to the universe? 3. Does one's spiritual life stimulate or hamper the growth of inner freedom and personal responsibility? Related issues include; the creation of healthy or unhealthy dependency relationships; mature or immature relationships with authority; and encouragement of the growth of mature or immature consciences.  56  4. Does one's spiritual life provide effective or faulty means of helping persons move from a sense of guilt or forgiveness? Does it provide well-defined, significant ethical guidelines, or does it emphasize ethical trivia? Is the primary concern for surface behavior or for the underlying health of the personality? 5. Does one's spiritual life increase or lessen the enjoyment of life? Does it encourage a person to appreciate or depreciate the feeling dimension of life? 6. Does one's spiritual life handle the vital energies of sex and aggressiveness in constructive or repressive ways? 7. Does one's spiritual life encourage the acceptance or denial of reality? Does it foster magical or mature beliefs? Does it encourage intellectual honesty with respect to doubts? Does it oversimplify the human situation or face its tangled complexity? 8. Does one's spiritual life emphasize love and growth or fear? 9. Does one's spiritual life give its adherents a frame of orientation and object of devotion that is adequate in handling existential anxiety constructively? 10. Does one's spiritual fife encourage the individual to relate to his unconscious through living symbols? 11. Does one's spiritual life accommodate itself to the neurotic patterns of the society or endeavor to change them? 12. Does one's spiritual life strengthen or weaken self esteem? These questions point to the hazards and strengths of practicing organized religion or other belief systems. They can be used also whether or not the client is presenting with primarily spiritual concerns. These questions suggest the comprehensive influence of the spiritual self; from relationships to neurosis, behavior and making choices. While these questions are impractical for clinical use, they have utility for purposes of reflection for the helping professional in observing their own spiritual self and in considering the possible influences of the spiritual self for the client.  57  Sims (1994). Sims (1994) takes a phenomenological approach in his assessment of the spiritual self of psychiatric patients. Sims distinguishes between obsessional symptoms and religious belief in patients through the clinician's phenomenological sense of the client's experience. To explore at this level Sims goes beyond the patient's religious affiliation to consider what meaning that affiliation has for the client. Further, Sims considers the client's goals, their sense of connectedness both with their world and their god, their sense of personal wholeness and their moral beliefs. Sims also advocates the use of community resources in treatment. He sees religion as important for psychiatric patients citing several studies which find religious activities beneficial for patients. His approach necessitates the clinician's knowledge of the client's religious affiliation. "One needs to know both about the shared assumptions of the religious group and the unique self-experience of the putatively disordered individual" ( Sims, 1994, p. 442). Sims (1994) is advocating a role for psychiatrists that is at odds with common medical practice because of its phenomenological premises. He agrees with Peterson (1987) that spiritual belief is an overlooked aspect of psychiatric care. He needs to go further in discussing mterdisciplinary care for patients and commenting on the responsibilities and hmitations of Psychiatrists doing this work. More than the other models discussed, Sims' work outlines the importance of the counselor's sensitivity to the client's experience of their spiritual self. Westwood (1995). Westwood (1995) suggests an open and direct approach to assessment of the client's spiritual self. Notable in this regard is his use of the question "So who's your god?" (personal communication, June 12,1996) and he notes that clients know what he's talking about. He suggests that the professional "(1) ask directly what they think their god wants of them, (2) explore with them their goals, hopes, dreams and what is expected of them, (3) acknowledge that others find it helpful to communicate beyond present  58  experiencing through meditation and prayer, and (4) find out how their behef has helped them in the past and perhaps in the future" (p. 2). Unlike the previous models, Westwood's model takes as its premise that there are many faces of the spiritual self. According to Westwood, the spiritual self "is that aspect of the individual which is transcendent which includes notions of purpose and meaning for the individual and typically expresses itself in cultural, creative and/or rehgious presentation. It is the component of the self which seeks or shares ideals with others and provides a basis of hope. Included in this realm are wishes, dreams (met and unmet) hopes, journey, a mission, soul, perceptions of being cared/loved beyond this world" (p.l). Westwood (1995) argues that attention to the spiritual experience of the chent is an important aspect of counseling. 'To better understand another we must acknowledge the other dimension which is often ignored in the helping profession - the 'spiritual self" (p.l). This model is important with respect to normalizing the spiritual self as an integral part of human functioning and an ordinary element of the counseling relationship. The other models discussed suggest that the spiritual self is optional and can be included or excluded from treatment. As a result of integration, Westwood's model avoids the problem of pathologizing the spiritual self which even Peterson (1987) in her efforts to escape the influence of her medical environment continues to succumb to by using inclusion criteria. Westwood's work is important in expanding our understanding of the spiritual self to include more than a rehgious dimension in practice. Chandler. Holden and Kolander (1992). The model of assessment of Chandler, Holden and Kolander (1992), is based on their model of spiritual wellness. The illustration of the model is two perpendicular lines: A horizontal axis which represents a continuum from "repression of the sublime" to "spiritual preoccupation", and a vertical axis showing spiritual growth. They suggest that for growth along the vertical plane, one needs to be at the center of the horizontal axis which is  59  identified as the point of spiritual wellness. The polarities of repression of the sublime and spiritual preoccupation on the horizontal axis represent crises.  SPIRITUAL DEVELOPMENT  Techniques for Spiritual Development Techniques for Grounding or Working Through  Techniques for Sacrilization/ Resacrilization  REPRESSION OF THE SUBLIME  SPIRITUAL WELLNESS  SPIRITUAL EMERGENCY/ SPIRITUAL PREOCCUPATION  Figure 3. Chandler, Holden and Kolander's (1992) Model of Spiritual Wellness Note. From "Counseling for Spiritual Wellness: Theory and Practice" by C. K. Chandler, J. M. Holden and C. A. Kolander, 1992, Journal of Counseling and Development. 71(2). p. 170.  Using this model assessment occurs in three areas. Firstly, assessment considers personal development; age, maturation, health and stage of development in relation to each of the five dimensions of wellness. The dimensions of wellness are from their model of the spiritual self discussed earlier; the emotional, occupational, physical, intellectual, and social elements of the self. Secondly, assessment considers wellness along the horizontal  60  continuumfromspiritual repression to spiritual preoccupation. The third line of assessment considers the client's place along the vertical line of spiritual development. To address repression of the sublime Chandler et al. (1992) suggest participation in sacred activities and reading concerning sacrilization. To address issues of spiritual preoccupation they suggest grounding activities like gardening or walking and eating grounding foods such as grains or meats. Grounding activities are aimed at slowing down the process of spiritual emergence. In both of these crises there is also a need to stay with the process of spiritual emergence. Spiritual growth along the vertical axis is principally accomplished through methods of meditation. Chandler et al. provide a number of sources for the reader to refer to for addressing any of these areas. They advocate dream-level therapy, psychosynthesis, and experiential approaches. The horizontal axis of this model in particular is captivating with respect to considering a practical means for professionals to address the spiritual issues of their clients. On the other hand Chandler et al. (1992) do not address the question of the helping professionals' role in facilitating the client's spiritual growth along the vertical axis other than to suggest meditation. Their model is also highly individualized and fails to address the important element of relationship or community. Finally, while they talk about spirituality as a universal human phenomenon, the focus of treatment is almost exclusively spiritual issues. Conclusions. Models of integration of the spiritual self are helpful in raising the various issues involved in incorporating the spiritual self in practice. There are numerous issues of importance in this regard. The mode of integration can range from a specific interviewing framework to a phenomenological exploration of the client's experience. It is necessary to attend to what the Client's needs actually are and to consider the extent of their integration of the spiritual self. Recognizing that the spiritual self is a common aspect of human  61  functioning with diverse expressions in the experience of the individual is also important. To this end it is necessary to honor the Client's experience of their spiritual self. Case Presentations The following discussion considers the reflections of clinicians with regard to their own experience of incorporating the spiritual self in helping. In this section the importance of the practitioner's spiritual self in the therapeutic relationship becomes apparent. Holmes' (1994) Internal Family Systems Model. Holmes (1994) discusses the incorporation of the spiritual self in working with his Internal Family Systems model. The model is based on a concept of the systemic family within. He presents three cases. In the first one, the client has what Holmes caUs an 'epiphany', an experience of 'the god within' which has a substantial healing effect for her. This occurs during the therapy session. Holmes (1994) asks the somewhat ironic question "So what does a rational, objective therapist make of a chent having an epiphany in the mental health clinic office?" (p. 30). In the second case study he describes a chent's binding shame on account of an abortion. Her healing comes in resolving her relationship with a spiritual part of herself. Finally, Holmes describes a client who deals with a depression through the comforting presence of a spiritual part. Holmes (1994) comments frankly that he doesn't know how to understand these experiences yet he discusses the tremendous need to connect chents to these spiritual places of healing and wisdom within themselves. He finds that his inner work with imagery sometimes has the effect of deepening the chent's spiritual life. He alsofindsthat chents with strong spiritual lives connect readily to this aspect of themselves in the therapy room. Finally, he notes that these spiritual parts of the chent can change from affirming and assisting roles to less supportive and sometimes demanding roles. Holmes (1994)findingsare inconclusive but they suggest several elements of interest. The first is the diversity of the work which incorporates the spiritual self. Secondly the profound potential for healing which the spiritual self is capable of. Davis  62  (1986) notes in fact that one spiritual experience provided the healing for him that nine years of psychotherapy hadn't been able to provide. Holmes' observation of the ready access to the spiritual dimension characteristic of some clients is also worthy of note as a resource that may often be overlooked in counseling. The Therapist's beliefs (Walter. 1994). Walter (1994) discusses how his Buddhist beliefs and practices are central to his work as a therapist. Despite the centrality of his beliefs in therapy, he does not discuss his behefs with his chents and only rarely does he suggest koans for his clients to meditate on. Some of his philosophic discussion is reminiscent of Roger's person-centered work though set in the framework of Buddhist thought. He presents several Buddhist axioms in relation to his work with chents. These teachings include: Boundaries between entities are arbitrarily drawn; everything is perfect as it is; and, my job is to create a context for transformation. The axioms suggest the wisdom that is learned in spiritual disciplines and overlooked in a more scientific perspective.  Walter's (1994) work is a meaningful  exposition of the counselor's spiritual self in relation to their work attending to the journey of their clients. Further, it suggests the limitations of the teaching of counseling and psychology in preparing an individual to work in the profound and complex realm of human suffering and the search for meaning. Working with conceptualizations of God (Griffith, 1986). Griffith (1986) presents his technique of incorporating a family's or more precisely, the individual and collective family concept of God in his work with rehgious families. In this paper Griffith explores with three Christian families their understanding of the nature of God. In each case, following an initial exploration Griffith suggests that the family trust God's authority rather than their own to care for the individual or situation. Griffith (1986) seems to be playing God in his work with families when he uses rehgious language to talk about client's behavior. He also risks disrespect of his chents by adopting their rehgious language to convey psychological principles. For example: '1  63  relabeled Byron's obsession with his mother's safety as sin, in that it was a lack of faith in God's ability to care for her. I further insinuated that his lack of faith may have harmed his parents' marriage when he, too confident in his own strength preempted his father's natural position" (p. 610). Several issues arise from this example. The first involves the question of mvokmg the spiritually laden term "sin" to address inappropriate behavior. The second issue is in effect blaming the client for his parents' marital difficulties. The quote also demonstrates Griffith's familiarity with Christian teaching combined with careless use of that knowledge. Finally, Griffith seems focused on a professionally forced resolution to the situation without due attention to the process of his clients. The question is raised as to whether Griffith has stepped outside of the domain of his professional authority by using what is a powerful frame for his clients to achieve his professional ends. One wonders to what extent his treatment may be in fact counter-productive. Griffith's (1986) work indicates by its neglect the importance of knowledge combined with spiritual sensitivity. It also points to the necessity of the professional's knowledge of their humbleness which the following author recognizes. The Transformation of Relinquishment (Anderson. 1994). Anderson (1994), presents a case study of work with a couple. The primary element of change is an experience of profound healing which the female experiences one night as she sleeps. " 'I also remember, at one point, reciting the words, T relinquish,' as iftalkingto God. It was at this point, I experienced an incredible hfting or easing of the burdens I had been carrying around for so long. A clean and fresh sense of newness filled my body. Feelings I had not experienced in months began to emerge. I felt a love and an attraction for my husband that I hadn't felt since we first started dating'" (Anderson, 1994, p. 37). Unlike Holmes' experience this one occurred outside the therapy room but was significant in facilitating the ongoing process of therapy. Anderson (1994) incorporates the transcendent in the counseling process. The transcendent includes "experiences that occur within time, space, and story and yet  64  transcend our human ability to control, analyze, or fully explain them" (p. 38). He discusses that relinquishment is an effect of transcendence. According to Anderson, clients find that this experience of relinquishment effects change that their will power has been unable to achieve. Anderson (1994) also discusses the importance of relinquishment as a therapist. "For us this involves a willingness to let go of our sometimes feverish wishes and attempts to change the couples' relationship. It further implies a willingness to face and feel the depths of the partners' despair and hopelessness and our own anxiety about failing to help" (p. 39). Here Anderson suggests what is possibly the best alternative to the erroneous theoretical concept of neutrality by proposing the therapist's deeply human experiencing of the client's pain. "Relinquishment represents a willingness to let go of ...strategies and...face the essential aloneness and helplessness that characterize the human condition" (p. 39). This deep place of human unknowing is possibly the source of healing more than the therapist's attempts at neutrality. Anderson (1994) suggests daily practices which prepare him for the task of incorporating his spiritual self in practice. Every morning before I leave for the office I practice a relinquishment meditation. In it I practice mindfulness (Hanh, 1991; Kabat-Zinn, 1994) including attention to breathing and mcorporating a theme of "letting go of trying and allowing God to provide everything needed." During sessions I, at times, tune in to the rhythm of my own breathing, focusing inwardly on the words "in" and "out," and then adding to the inbreath the words "I am" and to the outbreath "letting go." This helps me to release my own change agenda for the couple so that change can occur naturally. At other times as I look at the couple, I visualize golden hght falling over them and I imagine the words "you are being loved" or "I love you", (p. 40) For Anderson meditation, relaxation, focusing and visualization are regular parts of the therapist's role. Anderson's (1994) work is a rare gem in consideration of the therapist's incorporation of the spiritual self in helping.  65  Religious Conservatism (Stewart and Gale, 1994). Stewart and Gale (1994) discuss marital therapy with conservative religious groups. The central issue of practice is using a cross-cultural approach. Background knowledge of the ethos of the religious system is a preliminary necessity for treatment. It is important to know some of the religious metaphors for religious figures. Creating a safe therapeutic milieu is necessary. A part of this is giving clients permission to discuss their spirituality, in particular their relationship to their godhead. If this spiritual relationship is negative or punitive for the client they work towards a more positive experience. Routine intake information includes such questions as religious preference, degree of involvement in religious activities and the degree of importance of religion. They also suggest that the client's language and reliance on religious tools such as the bible be used according to the client's lead. Stewart and Gale warn against contradicting what the client understands as spiritual truth. They suggest the therapist take the position of learner with respect to the client's religious belief structure. Stewart and Gale (1994) offer a case example in which a couple is quoting religious text at each other. The therapist uses this as the basis for therapy and sends the couple home to do independent research regarding their personal responsibilities in the marriage according to their religious teaching. The couple is subsequently encouraged to work together to create a working concept of marriage based on their combined understanding of their own roles and the nature of marriage as described in their text. In contrast with Griffith's (1986) discussion of working with the client's religious paradigms, Stewart and Gale's (1994) paper presents a model of working which respects the adherences of the client and the limitations of the therapist's authority. The functional tools suggested by Stewart and Gale (1994) are easily adapted to suit any conservative spiritual perspective. Their model of application is perhaps narrow in its scope and lacks some of the dynamism of incorporating the spiritual self in therapy. Conservatism may  66  form a portion of any spiritual belief system however and is an important element for the counselor to be aware of. Conclusion. This discussion has considered a cross-section of the diverse experience of therapists incorporating the spiritual self in their work. What it presents is the richness of the experience for the helping professional, the curative potential of the spiritual self both within and beyond the counseling relationship, some of the tools that the counselor may use in incorporating the spiritual self in working and the responsibility of the counselor to be not only intelligent but wise in their work.  Support for the Research Question Clearly the spiritual self has received considerable attention. It has been generally neglected in research however due to the methodological limitations of quantitative analysis. Repeatedly in the literature (Bergin, 1988; Sims, 1994; Tjeltveit, 1989), one finds that helping professionals are straggling against the limits of an exclusively empirical or positivist paradigm for models of human behavior. "The relationship between chent and therapist is a relationship between real human beings, between two whole persons. It therefore appropriately involves far more than technical operations" (Tjeltveit, 1989 p. 157). Methodological limitations are discussed in the following chapter, but there are other considerations as well which have contributed to a lack of research in this much discussed area of the spiritual self. Larson, Wood and Larson (1993) provide a careful and rigorous summary of the research studies on spirituahty in the past century. Their analysis includes the disciplines of family medicine, gerontology, internal medicine, pediatrics, family practice, geriatrics and psychiatry. They find that "in summary, over time and in various clinical fields, the systematic reviews published to date reveal neglect of studies on spirituahty. Although Dr. Aldridge encourages us to pay attention to spirituahty, altering this research neglect will not  67  be an easy task" (p. 42). They attribute the neglect to cultural naivete, the politics of academia and the limitations of the medical paradigm. 'We do not believe it is a malicious attempt to exclude its study, but instead involves two major factors: the 'anti-tenure factor' and exclusion by the dominant [medical] paradigm" (Larson et al., 1993, p. 42). These two factors are intertwined. 'To survive academically, the few investigators who study in the field often do so as an adjunct to their main interest, suggesting the new field [spirituality] amounts to only a marginal concern. Consequently, researchers hoping to obtain tenure may choose a more accepted line of research" (Larson et al., 1993, p. 42). Further, they find that a lot of research which has considered spirituality has worked from the medical model's assumption of pathology. On the other hand they also state that the situation is changing. As a result of the significant positive findings in their comprehensive review of spirituaUty in the medical literature of the past century they predict a major paradigm shift. "A growing number of studies demonstrate that spiritual commitment is associated with clinical benefit for both mental- and physical- health status. Results are so consistently positive and so contrary to prevailing academic ideas that we beUeve that mental- and physical-health professions may be on the verge of a transformation in the next few years" (Larson et al., 1993, p. 45). Their predictions seem to be warranted as numerous authors are beginning to outline research questions which are needing to be addressed. Several of these authors raise questions which are directly related to the present exploration of how helping professionals integrate the spiritual self in their work. Mack (1994) proposes that "an initial question concerns what approaches students and clinicians might take toward issues of spirituaUty" (p. 39). She is critical of the neglect of incorporation of spirituality in clinical practice. "The fact that many cUents view their spiritual Ufe as only appropriate for the reUgious setting implies a fair amount about psychology's agenda and not about the needs of the client" (Mack, 1994, p. 39). Finally, she points to the lack of professional knowledge. "An initial  68  clinical priority for professionals is establishing a strong awareness of the delineation's between religiosity and spirituality" (p. 22). Brent (1989) who's discussion outlines faith as a human necessity, ultimately points to the responsibility of the professional to be accountable for their spiritual lives. " If all that we've discussed... is true, then we as individual practitioners may need to come to grips with the place of faith in our own lives....As practitioners of reality therapy, it is responsible behavior on our parts to clearly understand what we believe in, because as we all know, our belief systems drive our personal and professional decisions" (p. 52-53). Bergin and Jensen (1990) have found in research that professionals are more interested in spirituality than is generally recognized: Although the professionals' rates of conventional rehgious preference and involvement are lower in some respects than for the public at large, they show an unexpected sizable personal investment in rehgion by mental health professionals. This involvement is much greater than would be anticipated on the basis of published literature and convention presentations in this field. There thus appears to be a significant degree of unrecognized religiousness among therapists. Some of this religious interest is expressed in conventional ways, such as in affiliation and attendance, but a sizable portion appers [sic] to be less conventional and more personal in form .(p. 6) Their observation suggests that the present research may be more broadly applicable than is generally understood in professional circles. Shafranske and Gorsuch (1984) demonstrate similarfindings.They claim further that clinicians whofindspirituality important in their personal lives also find it important in their professional hves. Drawing from the same data, Jensen and Bergin (1988)findthat professionals demonstrate a discrepancy between personal views and professional presentation with regards to their spirituality. 77% of those surveyed agreed with the statement "I try hard to live by my religious beliefs" and 46% agreed with the statement "My whole approach to life is based on my rehgion". At the same time only 29% of these therapists rated rehgious content as important in counseling." (as cited in Pedersen, 1995, p.10) The demonstrated lack of integration supports the present consideration of what it might look like to integrate spirituahty in professional practice.  69  The failure to integrate the spiritual component in practice is perhaps reflected in the failure to address spirituality in training. Kelly (1994) has found that less than 25% of 343 counselor training programs includes a course or non-course component which considers rehgious and spiritual issues. This number was substantially lower in state-affiliated than rehgious affiliated institutions. In meaningful contrast to this, just under half of the department Heads believe that spiritual-religious issues are important or very important and another 41% indicated that they are somewhat important issues in the preparation of counselors. Kelly makes the recommendation that; The counseling profession, and counselor educators in particular, might beneficially expand research and professional dialogue to include whether and how a consideration of rehgious and spiritual issues needs to occur as a regular part of counselor preparation (Kelly, 1994, p. 235). The present research question can be foundational in beginning to address this area of need. Finally, Westwood (1995) comments that the challenge for the professional is to be able to bring into their interactions with their patients and chents the dimension of spiritual self. There are a number of ways of doing this, but first the worker must reflect on their own experience and ask themselves how do they make sense of themselves in respect to this part of the self. (P- 2) How this challenge has been addressed is the subject of this research.  Related Research Little research has been done to date that considers how the spiritual self has been incorporated in practice. The research which comes the closest tends to focus on some combination of religious orientations, values orientations and the interaction of these orientations with the counselor-chent relationship. The vast majority of the studies are also quantitative which limits the depth of findings in contrast with the present study. A number of studies consider the interactions of the religious views of the chent, the counselor or both together, with the counselor's practice of therapy (Gibson and Heron, 1990; Hillowe, 1985; Houts and Graham, 1986; McKee and Worby, 1990; Worthington and Scott, 1983). The construct of rehgion varies widely from denominational constructs to constructs which 70  attempt to look at the degree of conservatism. There is a noticeable lack of research which works with constructs of spirituality. The reason is perhaps because of the difficulty of operationalizing the construct. The tendency once again is to use the constructs of religions (Fuchsberg, 1993; Millison and Dudley 1992). Following are three studies which come the closest to the research question "How do helping professionals integrate the spiritual self in their work?" The major consideration in selecting these studies centered around whether they actually address what the professional is doing and experiencing in incorporating the spiritual self in practice. This is essentially the question of "How?". It is complicated by a systemic view of the client and therapist from the therapist's perspective. Shafranske and Malonv (1987/1990) Shafranske and Malony (1987/1990) have asked 409 members of APA about their religious or spiritual orientations and their practice of psychotherapy. Their findings indicate appreciation for religious and spiritual issues in treatment. They find that the professional's personal spiritual orientations are related to incorporating the spiritual self in clinical practice. With respect to interventions they find that as the clinicians' personal participation in the intervention increases, their use of the techniques decreases. Prayer for example is less frequently used because of the necessary personal investment of the clinician. Shafranske and Malony (1987/1990) suggest that this reflects a professional reluctance to influence clients' spirituality. They also find that clinicians with more confidence in their belief systems experience more competence in addressing spiritual issues with clients. Finally, they discuss theirfindingthat 85% of the 409 clinicians surveyed had little or no training in the area of incorporating spirituality or religion in their work. The acknowledged hmitation of the study is the response bias of clinicians who favor a spiritual perspective. This study has limited application to the present study because of it's focus on religious belief structures and its limited consideration of how professionals incorporate the  71  spiritual self in the work. The limitation is due to the use of quantitative methodology. Their findings however do consider some elements of how the spiritual self is incorporated. Millison and Dudley (T992) Milhson and Dudley (1992) asked 117 Hospice Caregivers about their use of spirituahty as an element of practice. Their focus is on how the caregivers help patients with their spiritual or rehgious needs. The caregivers represent a range of helping professions including Program Directors, Administrators, Nurses, Clergy, Social Workers, Psychologists and Physicians. 71% of the respondents express that spirituahty is an important element of hospice care. 39% of the caregivers initiate discussion on spiritual issues during assessment. Considering how the helping professional's spirituality is expressed; 52% introduce their spiritual views when asked by the patient, 15% introduce their spiritual views when they feel it is appropriate for treatment, and 8% never introduce their spiritual views. 94% of the respondents do not link their treatment approach with a particular rehgion. Further, 63% have no preference regarding the spirituahty of their patients. The respondents also express that Clergy carry the major responsibility for spiritual care though the researchers question this practice hmitation. Listening to the patient talk about God, and involving Clergy are the two principle interventions used. A principle limitation of the study is the limited use of methodological procedure. A research question is not identified with the result that the issues addressed seem random and lacking connection. Related to this, the findings are based on the limited information provided by percentages. For the purposes of the present study, the spotty bits of information are of interest but faU short of expressing a working concept of the spiritual self in practice. Cohen f1986) Cohen's (1986) study examines the experience of psychoanalytic clinicians who also have a rehgious affiliation. His analysis considers three dimensions of their  72  experience, (a) the degree to which they have integrated psychoanalytic and religious perspectives, (b) their personal psychoanalytic therapy concerning their religious issues, and (c) their clinical experience with religious patients. Cohen's study parallels the current study in its interest in the system of the counseling relationship with a focus on the counselor and on the spiritual dynamic. In the following section the relationship between the spiritual self and religious experience is again an underlying assumption. Some of Cohen's findings then have direct relevance to our discussion. For the sake of brevity, Cohen's extended discussion has been divided into three main points: theory, professional issues and issues in technique. Theory. Cohen (1986) conceptualizes a dual god. On the one hand there is the public god represented in churches and in public discussion, including that of therapy. On the other hand, there is a private god who function[s] like a special kind of transitional object, operating in a unique transitional space, which is largely outside the realm of normal consciousness. It play[s] a unique role in maintaining the psychic equilibrium of each individual in its role as attendant and observer of the real self. (Cohen, 1986, p. 178) As Cohen pushes his Co-researcher's into deeper exploration of their god-representations, hefindshis usually articulate subjects became arcane, embarrassed and mute on the subject. As a result, Cohen postulates that the public god must be intellectually defensible to allow for coherence of self as experienced in relationship with the private god. If this is not possible Cohenfindsthat the individual either develops more amorphous public gods or they abandon their religion. Cohen's (1986) conceptualization is meaningful for our present study because it indicates the enormity of the task of exploring the spiritual self in counseling. To discuss their spiritual selves, the Client risks a tremendously vulnerable part of themselves in presenting their public spirituality. Alternately, the private spiritual self may have only very limited means of being directly considered in counseling. It can be seen that this difficulty is the source of virtually all subsequent findings. 73  Professional Issues. Cohen (1986) largely supports Grimm's (1994) comment that clinicians with a spiritual perspective may be conflicted in the relationship between psychoanalysis and religion. His Co-researchers resolve the difference through rejecting either their rehgion or the tenets of psychoanalysis, or through a "compartmentahzation of codes" whereby they keep the two areas distinct. Cohen notes however, that once the Co-researchers could acknowledge the irreconcilable differences, they experienced no further intrapsychic conflict. However Cohen (1986) notes "the first major conclusion of the study is that the anticipated higher order personal integration of the seemingly irreconcilable perspectives of psychoanalysis and religion seldom, if ever, occurred on the part of our sample" (p. 222). Whether this failure to integrate the perspectives is exclusive to psychoanalysis which has the rejection of rehgion in its origin, or whether there is a universal discontinuity between theory and spirituahty remains to be considered in the present study. Despite the fact that most of the Co-researchers (10 of 12) only indirectly addressed their rehgious issues in counseling, the religious convictions of all of them were affected by psychoanalysis. Cohen (1986) notes that "the findings of this study predict a clear diminution of rehgious involvement as a function of psychoanalytic psychotherapy" (p. 235). Cohen's findings indicate that the spiritual self is influenced whether or not the topic is directly considered in the counseling context. In counter transference issues, Cohen (1986) finds that his Co-researchers experience a strong tendency to get drawn into patients' descriptions of rehgious material. This creates a role diffusion and the tendency for Co-researchers to adopt a more ministerial posture. Further, Co-researchers experience a strong desire to help chents cut through maladaptive rehgious formations which they have worked on themselves. This desire leads to anger at the chent for hanging on to maladaptive behefs. The Co-researchers deal with their anger by becoming overly gentle in response. Ironically Cohen observes, this clinical response justifies the rehgious client's fear of having their beliefs attacked in therapy.  74  Issues in Technique. Cohen (1986)findsthat the Co-researcher's strategies in working with religious issues are directly related to their own experience of addressing rehgious issues in therapy. "Subjects who dealt exphcitly with personal rehgious formations in their own treatment tended to address these concerns more directly with their own religious patients" (p. 207). Cohen notes that this finding was true regardless of their current rehgious perspectives. Three areas of overlap between the Co-researcher's personal and clinical work were: 1. The exphcit choice of a clinician with a compatible rehgious perspective. 2. The tendency to not directly address religious issues in counseling. In general the original reason for seeking therapy was not due to rehgious issues but to other conflicts and difficulties. 3. An effect on rehgious belief regardless of whether or not this was directly addressed in therapy. Cohen notes Rizutto's prediction that changes in rehgious formations parallel the treatment process. "She sees this as stemming from changes in the patient's self-object representations as a direct result of therapy" (Cohen, 1986, p. 228). Cohen (1986) notes briefly that chents have a better chance of effective therapy if they are working with a clinician with compatible rehgious views. The basis for this observation is not apparent in his discussion except for an indication that the clinician may take more professional liberties with a client with compatible religious views than otherwise. The benefit of this is not discussed. The observation is interesting in the present context however because of the indication of the importance of spiritual sensitivity to the chent. In general, Cohen (1986) finds the Co-researchers reluctant to become involved in directly addressing rehgious areas of concern with their clients. Two of his Co-researchers, who are orthodox in their behefs set aside therapeutic technique and directly address rehgious issues with chents using their shared religious belief system. However, the  75  remaining Co-researchers are reluctant to do this finding that the clients who present with problems couched in religious jargon are usually engaged in significant resistance. These clinicians tend to reframe the conflicts or work indirectly to address issues underlying the religious concerns. The reason for this is that their experience of directly addressing such concerns undenriines the therapeutic relationship. They find a direct approach lead to the Client's fast retreat from counseling or else it significantly intensifies the client's guardedness. Concerning the pattern of neglecting to introduce religious concerns in counseling Cohen (1986) notes caution and sensitivity on the part of both the clinician and the client. Cohen suggests that clients are very reluctant to open up such a vulnerable area. "Clearly a strong resistance to subjecting one's cherished religious beliefs and highly meaningful subjective experiences to perceived reductionistic attack played a major role" (p. 226). As clinicians the Co-researchers are highly sensitive to this concern of clients on the one hand. And sensitive to their personal reactions to clients maladaptive religious formations on the other hand. Both of these sensitivities tend to create an avoidance of religious material. The Co-researcher's also note a tendency for clients to ascribe priestly roles to them. The clients' desire for a spiritual director, or an idealized figure who could give counsel, support and at times absolution was noted. Again the clinicians are reluctant to directly address these transference's especially early in therapy because of the negative effects on the therapeutic relationship. Similarly, the Co-researchers do not directly address the issue of the client's request for a clinician with a given religion early in therapy. All of these issues may or may not be directly addressed at some point in therapy. One example of directly addressing an issue with a client is in a Co-researcher's recognition of a client's tacit demands for a religious affiliation. In an effort to offset possible future tensions in working with a fundamentalist, the clinician states "You're probably more devout than I am, but that doesn't matter to you, does it?" (p. 212). Clearly, Cohen's work suggests the  76  necessity for caution, creativity, knowledge and experience in working with clients who present with spiritual concerns. Finally, all of the clinicians find religious development as a powerful means of gaining insight to the client's object relations, personality style and overall level of psychological maturity. Cohen (1986) makes this final comment: "While the analysis of personal religious experience may indeed mark a royal road to the unconscious, it is a path that is highly defended and one that presents very real clinical dangers. As such, despite its clinical richness, it is one that is only rarely transversed" (p. 219). Limitations of the study. In general Cohen's (1986) study is exploratory and excessive in its scope of material. As a result he notes that "many of the conclusions offered must be viewed as highly tentative, if not outright speculative" (p. 234). In particular he draws attention to the singular population that he has chosen. Not only are they unique within the profession of psychoanalysis, notably all but one of them were men, all but one were ordained, and all but two represented liberal theology. Though the design of his study is admirable, the analysis lacks cohesion as it seems to wind in endless circles of discussion. Frequently repeating himself or introducing unsubstantiated ideas he leaves the impression of a lack of closure on the study, and uncertainty regarding the findings. At the end of the study, a further exploratory study, more refined in its nature is necessary to consider some of the observations he has made. Cohen's (1986) work is hrnited in its relevance to the present study also. First of all there is the question concerning to what extent Cohen's concept of religious is related to our present discussion of the spiritual self. He lacks a clear definition of his term, yet it seems to be related to having or having had at one time involvement in an institutional religion. Hisfindingsregarding the Co-researcher's current experience of religion have more of the nature of the individualized spiritual self considered in the present study.  77  Another significant limitation of Cohen's work for the present study is his focus on psychoanalysis. The disharmony between religion and psychoanalysis is more clearly documented than that between spirituality and other theoretical approaches. Further, his discussion within a psychoanalytic framework may have limited application for professionals from other theoretical disciplines. Finally, Cohen's (1986) approach with his Co-researcher's was to explore their religious experience through the lens of psychoanalysis where the approach of the present study is to consider how the Coresearcher has uniquely combined their experience of the spiritual self and their practice of helping. A final limitation of Cohen's (1986) study for the purposes of the present study is that in focusing on religious experience, Cohen has created inclusion and exclusion criteria for considering the involvement of the religious in counseling. The present study assumes that the spiritual self is a human phenomena involved in the process of counseling. Cohen's work actually supports this idea though indirectly. Hisfindingthat religious belief was affected regardless of whether or not it was addressed in counseling supports the present notion that the spiritual self is an implicit part of counseling.  78  CHAPTER 3 METHODOLOGY  It is unfortunate but telling that the view of man of modern positivistic psychology is such an impoverished and spiritually diminished caricature of "optimal man," a man or woman without self, soul, psyche, love, God—"Man the naked ape" rathe than "man made in the image of God." Modern secular psychology has fashioned an image of man that is far less than the divine revelation of the image of man as expressed in the great primordial religions. Even if these theories call themselves humanistic and existential they arrive at best, as Vitz (1977) has convincingly demonstrated, at a quasi religious position of the idolatry of self. Without a genuin openness to and recognition of the reality and inescapability of the theo-dimension and god-consciousness (Von Eckartsberg, 1981b) in human life and experiencewithout a realm that is superordinate and hence "ruling" and inspiring, passionarousing, value-positing, conscience-creating, relationship-establishing, and loyalty-demanding—the level of human self-consciousness and willfulness, of psychological theorizing, remains shallow and inadequate, unable to account for th fullness of the human life-drama. ( Von Eckartsberg, 1984, p. 205)  Introduction and Research Question In an effort to address the reductionistic view of people in research and practice described by Von Eckartsberg, (1984) above, it is the purpose of this study to examine the way in which helping professionals are incorporating the spiritual self in their work. The research question is "How do Helping Professionals incorporate the spiritual self in their work?" This question will be asked with reference to their practical, professional, and theoretical experience of incorporating the spiritual self. The following discussion will examine the choice of existential phenomenology to address the research question, and begin to implement that methodology by presenting the author's presuppositions regarding the spiritual self in professional helping. From this discussion the questions for the interviews emerge, followed by proposals for the selection of Co-researchers, procedural tasks, and analysis of the data.  Rationale for the Methodology We have discussed that the spiritual self has been an awkward bedfellow in the history of counseling. In considering the methodology for the present project then it is 79  improbable that we could easily adapt to a traditional scientific paradigm. There are however practical considerations which also negate the use of a quantitative design. In the first place, a quantitative design is not appropriate because the proposed research question lacks sufficient research to provide a basis to build on. The research needed at this time is theory building. Secondly, the definition of the spiritual self has not until recently been refined enough for quantitative research. Research constructs have been either too broad or too narrow for meaningful apphcation. Further, quantitative methods of research have not been able to address non-material elements of human experiencing. Giorgi (1984) makes clear the problem of researching human experience rather than behavior, in the traditional research paradigms of realism, empiricism and positivism. The postulates of these philosophies are such that they demand an explanation in terms of spatiotemporal presence and physicality, while everyday experience — conceptual analyses and the analysis of the meaning of these phenomena... all indicate that what is required is a "presence without physical referent", (p. 215) Related to this, methodology that aUows the Co-researchers latitude in their contribution to the research thereby incorporating breadth of exploration rather than finite data is more desirable in building a working model. In conclusion, given the proposed research question, quantitative methodology is philosophically incompatible and practically inappropriate for meaningful research mvestigating the spiritual self. A summary of several major quahtative methodologies in comparison with existential phenomenology is given by Osborne (1994). A review of that source outlines the decision making process regarding the appropriate methodology. Accessing the Coresearcher's highly experiential sense of the incorporation of the spiritual self in helping is the objective of this study because it is the nature of the construct of the spiritual self. That a personal exploration is required minimizes the utility of ethnography, participant observation, and dramaturgical interviewing for the present project. The choice regarding existential phenomenological methodology versus grounded theory or content analysis rests principally on the fact that both grounded theory and content analysis may employ theory in analysis of the data while existential phenomenology 80  doesn't. According to Krefting (1991), " the phenomenological approach asks what it is like to have a certain experience. The goal is to describe accurately the experience of the phenomenon under study, not to generalize to theories or models" (p. 215). It is apparent from the literature review that theory regarding the application of the spiritual self in helping abounds despite hmited supporting research. Basic existential-phenomenological research is needed for the purpose of morerigorousreflection on the proposed theories and for developing a working model of incorporating the spiritual self in helping. According to Owen, (1994), The existential view is ... a critique of research and therapy based on mechanical metaphors, statistics and insufficiently rigorous models for human science [italics added]. Existential-phenomenology claims a more reliable and accurate basis for . building an acausal, non-reductionistic and non-reifying philosophical psychology for understanding human nature. This is based on induction, drawing general inferences from particular instances and grounding in a priori essences, by first of all creating pure descriptions of actual sense experience. (p. 262) The process of applying the existential phenomenological method begins immediately with a careful and essential reflection on my biases in the project.  Personal Bias The source of existential phenomenological research is the researcher. Phenomenology acknowledges the human element throughout the process of designing, implementing and analyzing research material. The origin of existential-phenomenological study then is the careful consideration of the researcher's relationship to the subject. The objective is not only to identify presuppositions, but to use this understanding to discover "other criteria by which he can evaluate his research endeavors and results" (Colaizzi, 1978, p. 58). It is reasonable to concur with the husserlian school which questions the extent to which this can be accomplished. This observation however does not negate either the validity of the effort or the potential of good effect for the research. Owen (1994) describes the task: "Bracketing (the psychological epoche). Start afresh. Aim to set aside as  81  much as possible of your current knowledge, expectations, assumptions and attitudes about your subject. Reject all assumptions of causation" (p. 266). I have assumed a post modernist perspective in this paper (Jencks, 1987). Essentially what this means is that I have set aside the structures of authority and tradition in favor of a more pluralistic view. This is perhaps most evident in the use of a construct of the spiritual self rather than more traditional religious or psychological constructs. It is also apparent in the use of qualitative rather than quantitative methodology. A post modernist position values difference rather than the collectivity favored in the modernist school. Uniformity in post modernist minking is equated with suppression and taboos. On the other hand, modernism sees post modernism as a threat to culture because it undermines social structures, post modernism assumes that pluralism is the constant and by this view it enhances the significance of the individual's working out their personal convictions. In preparing this paper, post modernism (Jencks, 1987) gives me the opportunity to explore and convey my personal understanding of the spiritual self. This is done with no apologies to the reader who, in post modernist minking, is more likely to find disagreement with my exploration than wholehearted agreement. The value of the project for the reader is their own self discovery regarding the spiritual self. In post modernism there is no point of arrival but a constant movement between the dark and light sides of understanding. The right in what I have explored is irifused with what is wrong and vice versa. The first two chapters reflect personal learning and considerations regarding the spiritual self in helping professions. In a sense then, the first two chapters are my initial efforts at bracketing my experience of the spiritual self as it is incorporated in helping professions. The discussion regarding the person of the counselor in chapter one demonstrates this in particular. To further bracket my own experience of incorporating the spiritual self in helping professions I need to address the question "Why am I asking this question?". Simply put, throughout my training I have had a profound personal sense of the division between the  82  science and art of counseling. I don't know what the art of counseling is if it isn't spiritual, and even then I don't know what it is in practice. At a primary level then, I have a need for integration; personally and professionally. There are at least three other issues which have also contributed to my question. First of all my own spiritual hfe is a tremendous personal resource. Setting this aside as a counselor has left me with a strong sense of being at some level cut off in relation to my client. This seems in contradiction to the preferred practice of being fully present to the client's experience. My goal here is not to be able to proselytize with chents. Nor am I inclined to move into spiritual direction. This leaves me in a quandary regarding the question of "How do I incorporate the spiritual self in counseling?". Further, in my counseling practice I have been aware of clients struggling with spiritual issues and I am not equipped to explore the issue with them at aU. Sometimes clients come to me specifically because they know about my spiritual hfe and still I don't know how to incorporate the spiritual self in practice. Finally, my own experience of change has touched the existential roots of my experiencing and has required spiritual wisdom and support to integrate. It seems to me that change goes deeper than insight and different patterns of behaving. I have a hunch that at some level change has to do with spirituahty.  Summary of Presuppositions The following presuppositions emerge from the above discussion as well as the literature already reviewed. Presuppositions regarding the use of the spiritual self in helping come under five topic areas; definitions, the professional self, theory, technique and training.  83  Definitions Helping professionals who incorporate the spiritual self (HISS) in their work have a concept of the spiritual self. It is assumed that their definitions willfitthe research definition to a greater or lesser extent. Professional Self HISS see the spiritual self as important in their personal and professional lives. Theory 1. HISS have experienced conflict between their theoretical and spiritual frameworks. Grimm (1994) suggests this may be more the case for counselor's than for their clients because theory and spirituaUty are often at odds. 2. HISS have developed theoretical guidelines regarding the incorporation of the spiritual self in their work. This view rests on the understanding that the incorporation of a spiritual perspective does not render theory irrelevant, rather it may enhance and refine theory. Tjeltveit (1989) suggests that in fact a spiritual orientation provides a fuUer conception of the human condition. 3. HISS have views of suffering and healing that are related to their concept of the spiritual self. Technique 1. HISS use a range of techniques that are related to their views of spirituaUty. Some examples may be; prayer, meditation, confession, attendance at a place of worship, and visual imagery. 2. HISS respect the spiritual experience of their cUents and engage in dialogue in this area with some concepts of appropriate technique. Training HISS find that training in the area of spirituaUty is badly needed for helping professionals.  84  Procedure Selection of Co-Researchers Co-researchers were selected on the basis of (a) their having incorporated a view of the spiritual self in their work, (b) their ability to articulate this approach (c) their availability for the project and (d) the reports of colleagues regarding their suitability for the project. According to Colaizzi (1978) "Experience with the investigated topic and articulateness suffice as criteria for selecting subjects" (p. 58). Four Co-researchers were involved in in-depth interviews. Two participated in pilot interviews and two in the research interviews. Participation provided the Co-researchers with the opportunity to articulate and thereby possibly further refine their own theoretical and practical knowledge. In considering the background in the literature, the advantages of participation for the Coresearcher may have been further enhancement of counseling skills, the reduction of counter-transference issues and greater consistency between practice and research. Further, the Co-Researchers have had the opportunity to contribute to a burgeoning body of knowledge. The Co-researchers were identified through networking and contacts. Initial contact was made in writing with an invitation to call the principle investigator or the coInvestigator of the project. The initial contact included an information sheet with the name of the referring person (See Appendix A). Two Co-researchers were approached, and both Co-researchers were very interested in being a part of the project. In both cases the Coresearchers were considered highly suitable for the project as both had professionally incorporated the spiritual self in their work in practical observable ways. Pilot Interviews Two pilot interviews were conducted. The first was conducted while the interview was being developed. A male sculptor offered to take this role. While art is not within the domain of helping professions, it was considered that the creative act was in some ways  85  similar to the process of counseling. Further, it was ascertained that the Co-researcher had a strong spiritual orientation in his work. It was hoped further that this interview could give a brief glimpse into the applicability of the research question in other avenues of interest. This interview was conducted in the artist's studio. The artist provided helpful feedback regarding how the interview could be made to elicit a story rather than a point by point representation of experience. The second pilot interview was conducted in a counselor's office. This female counselor specializes in grief therapy. This counselor has a strong spiritual orientation though the extent to which it was incorporated in her work is unknown. This counselor has conducted similar research interviews which was considered an added benefit in pursuing feedback regarding the present interviewing protocol. She was an interested participant and provided excellent feedback regarding opening the discussion, enhancing spontaneity in the discussion, and providing guidelines to set the Co-Researchers at ease regarding the intentions of the project. The pilot interviews were an essential part of preparing the interview guideline and format. They also helped considerably in aiding awareness of the vulnerability of the Coresearcher in exploring this area. Co-researchers For reasons of confidentiality the gender of the Co-researchers has been disguised. The first Co-researcher is a Physician working in the hospital. Dr. A is in the mid forties and has practiced medicine for the past 10 years. Dr. A approaches life from a Christian perspective. Dr. A has lectured on the topic of spirituahty and is involved with research examining spirituality. Ethics and pubhc awareness of the spiritual-psychological elements of suffering and dying are interests of Dr. A . The second Co-researcher works in a community agency. B has an MA and is a Registered Clinical Counselor. B speciahzes in Trauma issues and currently works as a therapist, clinical supervisor, coordinator of the trauma team and is in a management  86  position. B is almost 50 years old and has been counseling in various capacities for the past 28 years. B has no religious affiliation. Aside from incorporating an awareness of the spiritual self in various working roles, B has spoken on the topic and is part of a worldwide discussion group. Interviewing The Interview questions emerged from the presuppositions. The interview itself however was based on Weiss's (1994) model for qualitative interviewing. Following is a discussion of the operational premises of the interviews. Weiss (1994) discusses the fact that the interviewing process fluctuates and changes throughout the process of each interview as well asfromone interview to the next. For purposes of reliability and validity Weiss suggests the use of a diachronic model of interviewing which ehcits a story rather than the series of points ehcited in a synchronic interviewing model. The depth of having the respondent get caught in their story rather than relying on an analyticalframeworkof discussion creates more trustworthy results. Further, the use of examples avoids the problem of generalized statements which serve to put the Co-researcher rather than the researcher in the analytical position. He uses semi-structured interviewing which emphasizes the Co-researcher's lead. Having established a relationship of good rapport, Weiss (1994) suggests one begin the interview with where the Co-researcher's interests he, and follow this lead giving directions only to keep the discussion within the framework of the study. A part of keeping the interview within the Co-researcher's domain of authority is spending time with the Coresearcher andfindingout together what kind of information this person can add to the study. Given an individual's preferences and areas of interest, they may be more willing to explore in some areas than in others. Commenting on existential phenomenological Interviewing, Osborne (1990) suggests that "open-ended, minimally structured interviews are more likely to produce data which might otherwise be missed. Reminding oneself that the aim is to allow the data to  87  speak for themselves is advisable" (p. 85). The open-ended minimally structured interview is in keeping with the goals of existential-phenomenological research to explore the Coresearcher's experiencing of the topic area. According to Osborne (1994) "The researcher tries to reach the prereflective level of experience. Prereflective knowing precedes verbal articulation. Some knowing is extremely difficult to articulate while some articulated knowledge may be second hand rather than actually experienced. The aim is to elicit naive descriptions of the actuality of experience as it is lived rather than to collect embellished and narratized accounts that are based upon what the participant believes is expected by the researcher" (p. 171). Weiss (1994) suggests that the interviewer use an interview guide to refer to at the beginning and end of the interview. This was done and the interview guide is included as Appendix C. He also suggests that the interviewer try to gain a conceptualization of the story the Co-researcher has told to see whether all of the pieces fit together. The guiding question for the researcher is whether he or she can re-construct the story because it hangs together, or are important parts missing. Finally, Colaizzi (1978) suggests that an approach of "imaginative listening" be incorporated. He describes imaginative listening as being fully present to the CoResearcher. Confidentiality and Consent The Co-researchers were given a duplicate consent form [see appendix B] stating the general purpose of the study and the time conimitment. They were reminded that they could terminate at any time. The Co-researchers were also given a grace period of two weeks during which time they could review the taped interview and withdraw it from the project if they so chose. None of the Co-researchers exercised this option. They were also advised that the tape recordings of the interviews would be erased upon completion of the project.  88  Considering confidentiality, their names and gender have not been used. Each individual's profession has been identified with efforts to be as non-specific as the Coresearcher feels comfortable with. The second interview was an occasion to check with the Co-researchers regarding the personal descriptions and decisions made in an effort to maintain confidentiality. Other identifiers, such as place names or groups have been changed or removed. Confidentiality is a topic of particular concern using the chosen methodology with professionals. Asking a professional to reflect personally on their professional experience puts them at risk. For example, aggravation with the inevitable limits of one's professional model has a personal component expressed in the phrase "I can't stand this foolishness!" and a professional component expressed in the phrase "How do I pursue my ends given these limitations?" Of course both personal and professional expressions of experience will come out in an interview geared to ehcit spontaneous responses. In doing research with professionals however, the Co-researcher is asked to reflect on a personal level in a public forum. The personal component is essential and valuable for capturing the Co-researcher's experience in unadulterated simplicity. At the same time the personal component expresses the vulnerable aspects of professional life. This risk is without merit for the Co-researcher unless the professional's freedom to explore with impunity is insured. That confidentiality is a central concern then is abundantly apparent. When the topic is as intimate and vulnerable as discussion of the spiritual self (Cohen, 1986) this obhgation to the Coresearchers is paramount. Practicalities The Interviews were tape recorded at a time and place convenient to the CoResearcher. The first interview with the first Co-researcher took place in my counseling, with a follow-up interview at the Co-researcher's office. The two interviews with the second Co-researcher took place in the Co-researcher's office. Consent forms were signed before the interviews began [see appendix B]. The estimated time commitment for the Co-  89  researchers was two hours for the initial interview and one hour for the follow-up interview. In both cases the Co-researchers willingly continuedtalkingfor an extra half hour during the first interview as they found the topic tremendously interesting. The Researcher had a list of referrals available should they be needed for the Co-researcher. None of the Co-researchers requested such support however, nor did they appear to be suffering undue stress. The in-depth semi-structured, non-directive interviews were transcribed for analysis. The interviews included notes in a field journal in which I recorded personal thoughts, feeling, hunches, questions, and problems that arose. In addition I tried to capture biases or assumptions that I become aware of during the process. By this means Colaizzi's (1978) concept of "imaginative listening" was incorporated. Imaginative Ustening includes not only the recorded material but also perceived material and phenomenological reflection. Second Interviews The second interviews were used to validate the exhaustive descriptions and the descriptions of the Co-researchers. Because of the extensive length of the exhaustive descriptions, they were given to the Co-researchers in advance of the second interviews. In general the Co-researchers were satisfied with the final product of the exhaustive descriptions. The first Co-researcher commented that their views were well represented. The second Co-researcher commented that the document was impressive. Both however also expressed some hesitation with seeing their spoken word in printed text as both felt they would have expressed themselves differently in writing. The second Co-researcher suggested that on another occasion it might be worthwhile to request a greater time commitment from the Co-researchers and have them re-write their quoted comments. Both Co-researchers also requested some deletions and additions in the exhaustive descriptions because topics seemed unrelated or were more complex than what could be conveyed in a  90  single interview. Afinalelement of the second interview was deterrnining the appropriate limits of confidentiality. Revisions were made to the exhaustive descriptions and re-submitted to the Coresearchers. Both Co-researchers made somefinalrecommendations for changes in telephone conversations. Both also continued to be supportive of the project and both expressed an interest in having a final copy of the document. It was conceived by the CoInvestigator that both Co-researchers have a sense of having shared something that is of immense value. In moving to complete this project, I have an acute sense of wanting to honor the gifts given by the Co-researchers in these exhaustive descriptions. Material for Analysis Colaizzi (1978) says that the material for analysis involves integration of the recorded material, perceived material and phenomenological reflection on the interview experience. These elements contribute to the imaginative hstening of the Interviewer and they can be achieved through the use of a field journal. Krefting (1991) proposes the use of the field journal for 3 purposes, (a) a daily schedule considering logistics of the study, (b) a methods log including rationale for decisions made, and (c) a kind of personal diary that reflects the researcher's thoughts, feelings, ideas and hypotheses generated by contact with the Co-researchers.  Data Analysis The analysis of the data reflects the format of Existential-phenomenology which is focused centrally on remrning "unto the things themselves" (Osborne, 1990). Typically existential-phenomenological analysis works with guidelines yet is emergent through the process of analysis. Osborne (1990) indicates that there is no orthodoxy in existential phenomenological data analysis. He recommends Colaizzi's (1978) and Giorgi's (1975) analytic procedures for those unfamiliar with phenomenological methodology. Starting  91  from these works the analysis of the data evolved and was influenced also by in interaction with committee members. Following is a summary of the analytical procedure. 1. Re-read the transcripts to get a feel for the interview 2. Break the interviews into meaning statements 3. Reduce the individual meaning statements. This was embarked on out of personal necessity as it allowed me to more deeply reflect on the content of the meaning statements. 4. Develop the themes. This occurred in three stages of refinement. An initial sorting of the meanings into between forty and fifty themes, then into between ten and twenty themes andfinallyinto the present structure. The second interview which was more complex required one further re-sorting to further simplify the meming structure. The classification process was interactive. After developing the themes at each stage I drew mind maps to link the themes and create a visual representation of the major themes. The field journal was also an essential means of considering the meming patterns. 5. A decision was made to keep the analyses of the two interviews separate at least initially. It was clear that the emerging meming patterns were very distinct. The degree to which the two interviews would eventually be integrated would depend on the extent of overlap. 6. Re-coding the data for dependability. One third of the meaning statements for each interview was randomly sampled for re-coding. For the first interview recoding rendered 96% agreement for the major themes. Of that 96%, 80% were correct also for the subthemes. For the second interview there was 98% agreement on the major themes. Of this 98%, 86% of the subthemes were in agreement. It is conceived that the lower agreement among the subthemes reflects the greater complexity of the meaning statements. The percentages were considered acceptable. 7. Creating the exhaustive descriptions  92  8. Second interviews for verification and some further questions. The second interviews led to some involved revisions. On occasion it was necessary to take the material back to finding the meaning statements and analyzing the data from this place. 9. Creating the summary descriptions. A decision was made at this point to summarize the exhaustive descriptions both separately and in combination as there was a great deal of material that warranted further summary. 10. Based on all of the previous work, the findings were prepared.  Delimitations Because of the small sample size, the use of a sample of convenience and the limited amount of time spent with Co-Researchers the study has limited generalizability. Further, the study is limited by the inclusion of only those professionals who can articulate the incorporation of the spiritual self into their work. People who may incorporate the spiritual self in a meaningful but non-articulated way have not been included. A second important delimitation is that this study has not considered the effectiveness of incorporating the spiritual self in the context of helping. That the spiritual self is a feature of our human experience is an assumption of this project. This study is inclusive with respect to both theory and helping professions. This may be a limitation with respect to the implications of the study for specific professions or theoretical approaches. Efforts made on behalf of maintaining confidentiality including the exclusion of gender may have some limiting effect on the findings of the study. The Co-Investigator's limited research experience is also a hmitation to the study. The counseling aspect of the helping professional's relationship with their patient or client has been the focus of attention. Other dimensions of the work of helping professionals has not been considered.  93  Trustworthiness of the Study Krefting (1991) cites Guba's model of establishing trustworthiness in qualitative research. The four elements of trustworthiness in quantitative research are: (a) truth value, (b) applicability, (c) consistency, and (d) neutrality. Krefting has taken these elements and considers them with reference to qualitative research. Truth Value Truth value is the extent to which one establishes confidence in thefindingsfor the Coresearchers and the context of the study. Krefting (1991)suggests a number of strategies for establishing the truth value of the study which are more and less relevant to this study. 1. The proposed methodology incorporates truth value in the use of the field journal which includes (a) the daily schedule and logistics of the study, (b) decisions regarding methods and (c) a personal diary which captures the researcher's thoughts, feelings, ideas and hypotheses generated by contact with the Co-researchers. The field journal also contains questions, problems, and frustrations concerning the overall research process. 2. Checking back with the Co-researchers regarding the analysis of the data is another way of estabhshing truth value in the study. 3. Careful preparation and process of the interviewing is also important in establishing truth value. "The reframing of questions, repetition of questions, or expansion of questions on different occasions are ways in which to increase credibility (May 1979). Credibility is supported when interviews or observations are internally consistent, that is when there is a logical rationale about the same topic in the same interview or observation." (Krefting, 1991, p. 220). 4. Structural Coherence, that is, ensuring there are no unexplained inconsistencies between the data and the interpretations has been a focus of the analysis. Accounting for rival explanations and deviant cases is important.  94  5. Triangulation of data, that is a breadth of data gathered through the interview, the invitation to create follow-up notes, the use of the field journal, the second interviews and the literature review have all contributed to the truth value of the study. 6. The area in which truth value could be better established in this study is principally that of time. To spend more persistent and larger amounts of time with the Coresearchers would enhance the truth value of the study through minimizing socially desirable responding as a result of more familiarity between researcher and Co-researcher. On the other hand Krefting suggests that a close relationship between researcher and Coresearcher can take away from the truth value through taking away from the researcher's ability to accurately distinguish between the Co-researcher's and the researcher's experience. Further, both Co-researchers expressed views that the project addresses a needed area of knowledge. These comments may also affect any tendency to socially desirable responding. 7. Reflexivity, the experience and knowledge of the researcher, can address the limitations of time spent with the Co-researcher. I have some experience of interviewing, of recognizing socially-desirable responding and background knowledge in the area due to my research efforts. Applicability or Transferability Transferability refers to the applicability of the study to other contexts and settings. While a panel of judges is ideal, networking and referral served the same purpose in this study. Background information concerning the Co-researchers has also alleviated this limitation. " Another way to look at transferability is to consider the data rather than the subjects. Specifically, the researcher must determine if the content of the interviews, the behaviors, and observed events are typical or atypical of the lives of the informants." (Krefting, 1991, p. 221) In both cases the researcher was aware of the Co-researchers' particular styles being very apparent in the interviews. The first Co-researcher was clearly  95  very familiar with articulating the incorporation of the spiritual self in the practice of helping. This confidence is due to Dr. A's current research and professional speaking in a parallel area. The second Co-researcher took time in engaging the interview, apparently considering both the intentions of the project and the nature of the personal contribution that would be made. The counselor was deliberate in the contributions made. Consistency or Dependability Dependability is the third strategy and it considers whether the findings would be consistent with the same Co-researchers or in a similar context. To establish dependency the use of a code-recode procedure was used during the analysis. In this process the data was coded twice to ensure replication by the researcher. This process has been chosen rather than using a second researcher due to concerns regarding confidentiality. On the other hand variability is expected in qualitative research. Guba's (1981) concept of dependability implies trackable variability, that is, variability that can be ascribed to identified sources. Explainable sources of variability include increasing insight on the part of the researcher, informant fatigue, or changes in the informant's life situation. Another source of variability stems from the fact that qualitative research looks at the range of experience rather than the average experience, so that atypical or non-normative situations are important to include in the findings.(Krefting, 1991, p. 216) Neutrality or Confirmability Confirmability or neutrality is the final element for consideration of the trustworthiness of the study. It is established principally through the use of an auditing system whereby an external auditor attempts to follow through the natural history or progression of events in a project to try to understand how and why decisions are made. The process of preparing a thesis incorporates auditing through the process of the interaction between the Researcher and Committee Members. Every effort has been made to integrate trustworthiness throughout the design, implementation and completion of this project.  96  CHAPTER 4 RESULTS The purpose of this chapter is to present the results found in this study. The two interviews are sufficiently different in their focus to warrant keeping them separate in the analysis. This is in keeping with the nature of the spiritual self which is characterized by diversity (Chandler et al., 1992). It is also representative of existential phenomenology which aims to represent experience. The exhaustive descriptions are followed by an attempt at summarizing the major points of each of the exhaustive interviews. There are numerous overlapping elements of the interviews as well and these will be summarized at the end of , the chapter.  Introduction The structure of the analyses emerged through careful review of the data rather than an attempt to superimpose theory or other considerations on the material. Each theme represents a clustering of related sub themes found through the refining process of working with the meaning units of the interviews. The content of the interviews is highly personal raising concerns regarding confidentiality. To this end and because of the small number of Co-researchers, every effort has been made to disguise identifying factors including the gender of the Coresearcher. This has some impact on the exhaustive descriptions and their readability. To exclude gender it was found that either a personal or an impersonal voice could be used. For the first Co-researcher it was found that the personal voice was more suitable while for the second Co-researcher the impersonal voice was acceptable. The effect of the difference is that "He thinks that spirituality is important", becomes either "You think spirituality is important" or in a more authoritative manner "SpirituaUty is important". It was found that for each Co-researcher one overarching conceptuaUzation characterized the incorporation of the spiritual self in their work. The first Co-researcher  97  considers the incorporation of the spiritual self as a journey. The second Co-researcher focuses instead on the theme of transformation. These differences reflect the unique ways each of the Co-researchers have structured their thinking around the incorporation of the spiritual self in practice. Some substantial changes were made during the second interviews where the Coresearchers articulated some elements of the exhaustive description in greater depth. These points have been added with the notation that they are additions from the second interviews.  Exhaustive Descriptions Interview #1: The Integration of the Spiritual Self in Helping Professions is a Journey Premises of the Journey Spirituality and Being. You believe that we're not simply physical beings like the animals. Instead you find that spirituality is an inherent aspect of being "it's inherent in who you are and how you be". For you this is demonstrated in the relationships to self and other where you find there is something greater than the physical. At the same time youfindthat we have a quality of aloneness "we are alone" which is also demonstrated in our relationship to self and other. As far as you are concerned, this aloneness quality also points to spirituality as inherent. Divisions of the self into psychological and spiritual are largely random and irrelevant in your perception. You conceive that it is possible that they meet at some point. In your understanding, the distinction between the psychological and the spiritual has to do with relationships. The spiritual side is represented by a vertical relationship with value, meaning, or some Higher Power. The psychological has to do with horizontal relationships with self and others. You see that the connection between the two terms however is complex. For example, the horizontal "relationship with other people includes a  98  spiritual relationship of understanding, appreciation, value, recognition". For practical purposes they are virtually interchangeable hence you use the term " spiritual-psychological". You see journey as inherent in spirituality and spirituality as inherent in the journey. The spiritual journey as you understand it has to do with finding meaning purpose and value. The journey in your experience is dynamic bringing us different features in terms of our environment and our eternal selves. In your view resolution as described by Erikson is one of the end goals of the spiritual journey. Suffering. You have reahzed that while pain is physical and can be treated, the same cannot be said for suffering. "Suffering has to do with being cut off from self, others and a belief system. And I think suffering is equivalent to aloneness". This is illustrated in your experience of seeing patients who are cut off from any human connection to family, friends and even hospital staff. "Sometimes the suffering is so seems almost unrelievable, as if there's nothing that can be done to address it". While you have been able to address physical pain as a Physician, suffering has remained somewhat inaccessible to treatment and you think it cannot be completely abolished. In your experience, suffering which is beyond the physical may culminate in the patient's seeking death as a way out of the suffering. You feel that the inclination to selfinitiated death is linked to spiritual-psychological suffering. Healing. In your view, health is the experience of "choosing life's way". It is a choice that involves acceptance and resolution of one's journey in living. "It has to do with resolve, with accepting one's journey as to how one lived, some type of reconciliation for the regrets, exhilaration for the joys and also for individuals who can come to some sense that there's a purpose outside  99  oneself then healing can take place. I am a significant person in a world of 4 1/2 billion". In your experience, health has been expressed for example in contented, peaceful and calm acceptance of one's dying and death. You feel that health also has to do with connectedness. "That somewhere in the earth for sure I am significant to whatever, to continuation to compassion to love to fellow man whatever it might be. And that it's in caring for the self and at least one other person that my life has had meaning and inner contentment". Being connected to self, other and to something greater are important elements of healing in your understanding. "Through our lifetime we choose to embracc.who you are, embrace one or more relationships with some individual or people on an intimate level which requires commitment and a belief in a spiritual being, in God". Finally, in your view healing is not bound to age or length of life, nor is healing bound to cure. Dying and Spirituality. Your experience of ourfinitenature is that it brings people in touch with living "it's in acknowledging our finiteness that we cope with living well, a valued thing". You sense that the alone process of dying is connected to the choice of healing or suffering, "you don't necessarily have to die lonely. People who die lonely suffer, because they're cut off". In your view it is facing the reality of dying that raises our awareness of spiritual-psychological experience in life. Addition From the Second Interview. Using Erikson's concept of resolution you are finding your understanding of suffering and healing continues to evolve. You observe that there are issues that can be resolved and those that can't such as being pre-deceased by a child. "That which is resolved and resolvable can be healed....That which can't be resolved will lead to suffering".  100  The Journey Introduction. Your interview conveyed a central theme of the Journey which was expressed in six different areas; society's journey, the patient's Journey, the Journey of the medical model, the personal Journey, the professional Journey and the Journey of the team. Within these journeys which are both distinct and connected, there are four sub-themes including Origins, Struggles, Integration, and Looking Ahead. The sub-theme of Origins considers the beginnings of the journeys. The sub-theme of Struggles is characterized by a lack of resolution and a sense of working through issues. Integration has to do with integrated experiences of incorporating the spiritual self in helping. The Looking Ahead sub theme forecasts the ongoing development of the journey of incorporating the spiritual self in practice. For ease of reading, it was considered more meaningful to trace each of these journeys separately drawing attention to the four sub-themes within the journey than to divide the journeys according to the sub themes. Of the theme of the journey you commented in the second interview that "Although you don't need to be lonely, the journey is one that you do alone" This view is not a contradiction to the view that society also is on a journey though the social journey is a more complex concept. "Society has a journey too, the whole package of us is moving around. I don't know how that will work" Society's Journey. 1. Origins In your experience, society is afraid of death and denies its reality. You sense that social denial increases people's isolating sense of aloneness. Suffering then arises from this aloneness. It's a case of the proverbial '"I was in a crowd and I felt alone, I was on a mountain top by myself and wasn't alone' And I think that's true also for everybody today". You feel that today there is a lot of psychological and spiritual suffering and that as a society we don't know how to address it.  101  During the second interview you went on to say that you don't think we recognize that there may be spiritual-psychological dimensions to people's physical pain. You perceive that we will cope with physical pain until it interferes with our lives and then call the Doctor for rehef. In contrast to this however we don't recognize our spiritualpsychological pain and reach out for help with that. 2. Struggles You find that what's needed is fundamental social change to address the problem of suffering. You feel that society needs to integrate the spiritual dimension of living. You perceive that today, we haven't adopted or integrated a spiritual understanding. Social change in your view however is necessarily gradual and cultural for it to be in any way meaningful. During the second interview you commented further that based on the social response you have observed to media coverage of research into spiritual issues you sense that people are waiting for spiritual issues to be addressed. You don't think society necessarily knows what issues they want addressed, yet you perceive that it is related to issues of spirituality, rehgion, value and meaning in hfe. 3. Integration That your current research into spiritual issues has been funded is significant to you. 4. Looking Ahead In your work with a group of like-minded professionals, you are hoping that dying can be brought back into social consciousness through a gradual process of change in the culture. Together you will address social change through teaching, research and program development. You sense that greater social awareness of dying would have broad reaching implications for values, relationships and the search for meaning. The Patient's Journey. 1. Origins.  102  You feel that because of society's denial of death and inability to address suffering, your patients may not recognize that their suffering is psychological or spiritual. 2. Struggles In your view, sickness is not purely physical. "It impacts how we feel about ourselves it can impact how, if we have a belief system, it affects how we relate to God, it certainly reflects how our faith our religion might be constructed". You find that as your patients come to the place of facing death they may get in touch with their spiritual suffering.  "So that ...dying seems to put people in a  position where they're seeking meaning, seeking the spiritual, seeking some non-physical domain because they recognize that their physicallness has betrayed them and maybe there is something else". You find however, that being in touch with their suffering may or may not dispose them to address the issues of their spiritual-psychological pain. 3. Integration You related several stories of spiritual psychological healing for your patients. The stories demonstrate your model of healing through connectedness with self, other and some form of higher power. In one story a family's hfe together was substantially enriched after they had been gently confronted by a helping professional with their dysfunctional pattern of relating. The occasion of addressing their disconnected relationships arose in relationship to the illness of one family member. In another story you illustrated one patient's willing acceptance of death at a young age. In the story the patient is clearly connected with family members and with a sense that dying would connect him with a greater reality. Your story conveys a peaceful dying process.  103  For you the expression of integrated spiritual-psychological experience, that is, the expression of being healed, is found in contentment, calmness and peace in the face of dying. The Journey of the Medical Model 1. Origins You perceive that the medical model is disease and cure driven rather than illness and healing driven. "Doctor's don't go and say I'm going to look at this lung cancer, but the disease becomes the entire focus and the drive to be accurate in your assessment, your diagnosis and the treatment plan and you know get rid of this disease". You find that authority, power, knowledge and position are rewarded in the medical profession. Any professional risks appearing "flaky" in the medical world if they uphold a spiritual perspective in their work. You observe that this is ironic for a healing profession. Your experience is that medical training is a strong socialization process partially because the academic demands are so intensive. You feel that setting aside spiritual growth is a necessity while in medical school. "I think that in terms of what the literature which might say that as a professional you set that part of  yourself aside,  whether it's that concrete or dogmatic that process of medical school I think that is a reality in that in terms of going through medical school you need to be driven". You note generally that medical and nursing schools don't teach models of interviewing which follow the patient's lead. This preferable mode of interviewing is characterized by demonstrating in action, manner and words an openness and availability to the patient. It is described more fully in the theme of practice. 2. Struggles One of your medical research colleagues has privately observed to you that first and second year medical students are better at freely interviewing patients on any topic than are  104  psychiatric residents. This person finds that the residents are unwilling to give up their medical psychiatric model. It is your view that without a spiritual dimension to treatment, treatment is limited to a " medical disease model, disease driven model". You sense the limitation of this model in addressing patient's needs because their needs at times include a spiritualpsychological dimension. Physicians know well the problems of illness and disease. They are less knowledgeable about the spiritual-psychological dimension of personhood. In your experience, Physicians in general need education regarding the patientDoctor relationship. You also sense that they need more education in being fully comfortable themselves in their roles as Physicians. "Being comfortable in themselves. Being comfortable with their own mortality, their own spirituality because then they would also be comfortable in addressing that in their 15 minute visits in their offices". It is by this means that you see the spiritual-psychological dimension could be brought into practice more readily. 3. Integration In your research you are addressing the shortcomings of the medical model with respect to the incorporation of the spiritual-psychological dimension. "The medical model isn't all bad, but it certainly isn't all good. And what can I infuse into this to make it a sustainable and healing model". You are aware of one notable North American medical school which includes training regarding the patient-Doctor relationship. It is your understanding that an exploration of meaning and purpose of hfe even in relationship to cadavers is a part of the education process at this school. 4. Looking Ahead You anticipate that your current research project should bring credibility to the incorporation of the spiritual-psychological in medicine because it uses the structures and language of the medical model. "One of the currencies of medicine is research  105  and publication". Further, you sense that over time you have developed some professional credibility whereby you feel that you can grapple with the dynamics of power, influence and strategy that you perceive are a reality in the medical world. You feel that education regarding the patient-Doctor relationship should be available at more medical schools. You also think that learning regarding the patient-Doctor relationship needs to begin from day one in medical school. 5. Additions from the second interview You differentiate between a curative model and a healing model. The curative model as you describe it addresses basic physical sickness such as a child's earache. No further Doctor-patient connection is necessary. A healing model however is needed when the patient's illness is chronic ortenninal.In your view, a healing model addresses the whole person including the spiritual-psychological. You feel that both of these models are necessary in the practice of medicine as patients' needs vary. At times a patient needs simply physical attention, at times, a patient's illness has profound implications for their lives and they need to be met in a deeper place. Your area of practice requires treatment in the spiritual-psychological hence your focus on incorporating spirituaUty in your work. The Personal Journey 1. Origins The origins of your incorporation of the spiritual psychological in your work stem from some of your childhood experiences. Your early perceptions of unresolved adult relationships, exposure to numerous deaths and depression as well as your personal style of coping through supporting failing family members were all contributing factors in your view. You had substantial reUgious training during your childhood. Other influences included the personal interest of your Family Doctor and your backgroundtiainingin social sciences. You have a hunch that these moderated the pure science perspective of your medical training. Your appreciation of the hoUstic approach of a Doctor in the same area of medical practice was also a contributing factor. Finally, and most significantly, witnessing  106  the spiritual psychological suffering of your patients led to your clear recognition of the need for incorporating a spiritual-psychological dimension in your work. 2. Struggles During medical school you paid the price of developing aspects of yourself even though this was counter to your value system. Since then however, through the process of time and learning the novice desire to solve everything, to prove oneself and to be a hero decreases. "Once you're aware of [it] you're half way there". One of your learning processes has been listening and expressing things in a more personal and comfortable way with your patients. This is a different model of interviewing than the one you learned in medical school. It also took you a lot of time to learn to be fully yourself in the role of Doctor. You have been deeply affected by the suffering and healing of your patients. "I will never forget either of those two men". The process of caring has at times become personal to the point of raising issues of personal versus professional care for you. You noted that witnessing the absence of a parental figure at the bedside of some of your patients led to your personal exploration of family connectedness. Further you have on occasion experienced a sense of personal anguish over patients who choose not to address their suffering. At times your work seems overwhelming because you spend so much time with the darker side of lived experience. In your view working through personal issues is an element of the process of incorporating the spiritual-psychological in caring. " I had to experience my pain, acknowledge it, address it before it could become compassion. And I mean it took me a long time and the coaching of my good friends to get to that point". Issues of personal development also arise as a result of your exposure to the suffering of your patients. "It does become personal. I think the value of [my medical practice] is that issues are raised for me in my thirties and now my  107  early forties". You are concerned to make choices for what you understand as healthy and integrated living. "I want to make sure my own choices are made today". Though in your view the medical model can inhibit your personal journey by its exclusively physical focus, you find that your search for personal meaning and fulfillment becomes inevitable in helping. You sense that the incorporation of the spiritual self into your work has been and will continue to be a process. "I didn't learn this at medical school however I have wanted to be vulnerable in that, to be a student". The incorporation of a spiritual-psychological dimension in your work had its roots in medical school. You find however that it takes time for integration to occur. You don't perceive that integration happens for new graduates. It even took time for you to recognize your personal capacity to bring spiritual-psychological healing to your patient. You anticipate that change will continue because you are dedicated to incorporating the spiritual-psychological in helping. You also expect that incorporation of the spiritual-psychological in your work will improve as you get older. 3. Integration The personal journey within the sub theme of integration describes your personal experience of integrating the spiritual-psychological in your professional life. It also presents the personal practices whereby you nurture your spiritual self in an ongoing way. You gain a sense of personal resolution, meaning, value, satisfaction, pleasure and enjoyment from your work due to your incorporation of the spiritual-psychological component. Related to this, your specialization by its nature fosters a sense of personal meaning. You find the broad diversity of people and tasks gratifying. While you experience some personal cost in your work, you also find tremendous rewards. "I've had tremendous satisfaction of relieving people's physical pain...I think it's more gratifying to see people healing their relationship with their son or their daughter. So there's a lot of reward there".  108  For you the integration of the spiritual-psychological in your work has been an inevitability because of your prior spiritual comrnitment to a Christian way of hfe. "I approach my work from a Christian perspective, or try to (laugh), that is part of who I am and I don't believe I can dichotomize the spiritual from my work". You find that your personal spirituahty transcends your role as a physician. "In my role as a Physician sometimes there isn't a lot you can do. But in the role as a fellow human being who has a belief that there is a spiritual component and a psychological component, that there are needs there that need to be addressed and challenged and met if possible". This is not to suggest that the spiritual and the professional cannot be integrated, but that the spiritual component is somehow a larger reality than the professional component of your sense of being. You find that the effect of incorporating the spiritual-psychological in your work is comprehensive. "It affects how I do my physical exam, how I introduce myself to people, how I care for the individuals apart from their family". Your personal integration of your spiritual-psychological experience has to do with your connectedness to yourself, others and God. Youfindthat time alone; reading, praying and reflecting foster a deeper sense of yourself. Your relationships with your family and friends are important sources for your reflection and renewal. Your children in particular are a rich source of spiritual nurturance for you. Focusing on your consciousness of God and Christ provide you with a solitary sense of the meaning and value in life. You find that church attendance restores a sense of purpose for you. 4. Looking Ahead Your current research project will address your personal interest in continuing to incorporate the spiritual-psychological dimension in your work. This project brings together both your personal and professional interests.  109  The Professional Journey. 1. Origins You find that your area of medical practice is effective in addressing your patients' physical needs. In your work with your current patient population however you have experienced some novel issues for treatment. Of central concern for you was witnessing your patients' suffering in the absence of physical pain. Exploring this phenomenon has led you to a professional conviction regarding the necessity of incorporating a spiritualpsychological dimension in your treatment approach. You have developed a professional commitment to mcorporating the spiritual-psychological in your approach to treatment because it is continually reinforced to you that though a patient's physical pain has been relieved yet their suffering continues and can be excruciating. You commented in the second interview that you feel your area of practice brings the spiritual-psychological experience of living into focus. 2. Struggles In your medical practice it's necessary to address physical pain. You are also convinced however that it's a part of your role to develop skill and understanding of the psychological and spiritual components of being. Youfindthat integrating physical treatment with spiritual-psychological treatment is challenging and it is a matter of professional choice. "I see [disease] every day and I can choose to stay in the medical model and look at only physical pain and say that's my role....Or I can sit with this bigger issue". While you generally initiate an exploration of the spiritual-psychological experience of your patients at the time of admission, youfindthat if your patients are for some reason hesitant to engage the exploration at this time you may have to leave it for the time being. At times during admission procedures you feel caught between initiating your approach to treatment and addressing the hospital's requirements. Once admission is completed however you employ your approach to treatment which includes an exploration with the  110  patient of their spiritual-psychological experience. In the course of the working day, you also find that time constraints pose a considerable obstacle to the effective incorporation of a spiritual-psychological dimension to treatment. "It's more difficult [to incorporate the spiritual-psychological] than it is easy because of time constraints. If you had an hour with each patient it would be easy. But there's so much to do". 3. Integration In your experience, immersion in one discipline for a number of years is a necessary precursor to a professionally credible integration of the spiritual-psychological component in working. Through the process of time you have experienced a greater sense of credibility and courage. You have learned that time and experience create a fund of knowledge with respect to your professional practice and you can choose how to use it. You sense that the power of this knowledge can be used positively, negatively or it can be ignored. Used positively, you find that this power has a desirable impact on people. "When you make a statement...people will listen. And if they don't listen first of all, as soon as you say the program you're involved with has had thousands of people..., they'll prick up their ears". Youfindthat the addition of research to patient care provides a gratifying opportunity to spend more time with patients. "I get the best of both worlds". In your work with residents you engage a valuable training opportunity to demonstrate the spMtual-psychological dimension of interviewing and care of patients. "I'm very conscious of exaggerating the fact that I sit and that I ask them [patients] some non-medical questions whether it's their favorite music, or church music or belief system. I...try to incorporate one or two questions that they [the residents] probably haven't ever heard a Doctor ask before". Your intention is to give the residents an early opportunity to see and perhaps to become comfortable being themselves in the context of Physician's work. For you this personal  111  comfort took a long time to develop in part because you had to discover it on your own. "You don't have to be a Doctor all the time, just be yourself in the context of being a Physician". Youfindthat by including more than physical treatment, that is when you address the whole person of the patient you gain a sense that your work is meaningful. "I believe there's a bigger meaning to one's presence in their vocation. And I think if I just make it simple for me it's the Sunday school story of the Good Samaritan; caring for people without question. For who they are, where they've come from and recognizing that there's a need which sometimes we reduce to a physical need but there's a basic need to be loved". You find that the capacity to listen, to be accepting and to bring a spiritualpsychological healing component to patients puts one in a unique position for treatment. You sense that in this exchange the interaction of Physician and patient is infused by a sense that the existence of each is purposeful. You experience this exchange as purposeful and mutually meaningful "somehow the exchange is a method of love". In your professional journey you have experienced some existential aloneness in attempting to integrate the spiritual-psychological in the medical model. You feel that this is a necessary ingredient to begin to experience the aloneness of the patient. 4. Looking Ahead One of your professional goals is to influence change socially and professionally. You hope that your research will contribute to this. Finally, you anticipate that over time your understanding of spirituality versus religion will improve because you feel that spirituality is more reflective of your Patient's needs. The Team's Journey. 1. Origins From your review of the literature you have found indication that healthcare providers are not providing for spiritual issues as well as they mink they might be. You feel  112  that there is a wisdom that needs to be developed in addressing spiritual-psychological aspects of treatment. You sense that while in some cases it might be appropriate to wait for the patient to identify spiritual-psychological issues, in others, for example when a patient is dying, it may not be appropriate to wait. "If they've got spiritual and psychological pain, you've got to act now". You recognize that many people from different disciplines do a good job in treating the whole person. In the general picture however a holistic approach to treatment is a needed. You are currently working to develop a Team approach to addressing the spiritualpsychological needs of patients. A more complete description is outlined in the theme entitled "Practice". In general however, you want the team to operate as an integrated unit facilitating the patient's journey through their spiritual-psychological suffering. Your team is multi-disciplinary including many different professions, support staff and trained volunteers. From your literature review it seems that a team approach to incorporating the spiritual self in helping professions is not documented as having happened anywhere. 2. Struggles As it is developing, you sense that your team is in an ongoing learning process regarding the incorporation of the spiritual-psychological in healing. You feel that each of the disciplines on the team bring a lot though there's still a great deal of room for growing. In your view the team has not been able to consistently address the problem of nonphysical suffering and this is due to a lack of knowledge and understanding. You believe that the team needs to learn the skills of watching, listening, speaking, asking questions, and challenging people appropriately and effectively. The team has participated in communication workshops which you find provide a significant avenue of professional development with good effect for the patients. You note that so far the time spent in workshops has mostly dealt with the interpersonal issues of the team members. More recent work role-playing difficult issues and possible conversations with patients has provided the team with an example of skill development in your view.  113  In your experience, the incorporation of a spiritual-psychological approach is more straightforward with some members than with others. You note that team members have different levels of maturity regarding their availability for the patient's spiritualpsychological needs. When you consider team members who have more difficulty you note that some don't see and perhaps will not see the necessity of integrating the spiritualpsychological in their current work setting. You note further that some team members are unwilling to incorporate the spiritual-psychological dimension in their treatment approach. Some are unwilling to do the necessary personal work. Finally, you observe that some team members erroneously believe they know how to incorporate the spiritualpsychological dimension. You feel there are two principle factors which contribute to the difficulties members experience in incorporating a spiritual psychological dimension to treatment. First of all, you sense that a spiritual-psychological approach to treatment can conflict with the medical model approach to treatment. Secondly, you sense that team members' resistance to incorporating spiritual-psychological treatment may be the result of a perception that this is being forced by the program coordinator. You find that a power dynamic arises in place of recognition of the value of a holistic approach to care. "We are focused on this because we want to be patient-driven, patient-centered and that we believe that the psychological-spiritual components are inherent in who we are". For you working with these inter-personal factors to foster a holistic treatment approach is very demanding. In your view it may be more suitable for some team members to use their skills in a different environment. On the other hand, you note that some team members recognize the value of integrating the spiritual-psychological dimension. You perceive that they are doing the necessary personal work and are reviewing the deficiencies in their training. "There are a significant number of people who are interested in pursuing [the spiritual-  114  psychological dimension of treatment] and working together to learn and then working together to address the issues with patients as a team". 3. Integration You find that the team is a tremendously important means of incorporating the spiritual-psychological in treatment. "It is invaluable. One discipline can't do it all". You feel that an important aspect of the team's incorporation of the spiritualpsychological dimension is it's capacity to deal with the problem of limited time. 4. Looking Ahead It is your ambition that the Team will continue to evolve in the direction of incorporating the spiritual-psychological dimension astutely, wisely and in a finite amount of time. Your central considerations with this goal are limited health care dollars, and the emotional, physical and mental resources of helping professionals. You would like to find a formal means of interviewing and discussion. You hope that all team members will be able to reflect back to patients that their pain may have a spiritual-psychological dimension so that patients will be enabled to embark on their own journeys in healing. You also feel that the input of counseling psychology would be an asset to the team and this is one of your goals. In the second interview you commented that counseling psychology may be more adept at identifying spiritual-psychological pain than some other disciplines are. Practice The final theme considers the practice of mcorporating the spiritual self in the helping profession. You begin a discussion regarding the patient's spiritual-psychological experience during admission to the hospital. The admission form in your hospital includes a question regarding rehgious affiliation. You take the opportunity provided by this question to explore related dimensions of the patient's spiritual-psychological experience. You find that questions such as "Is that significant to you now?" facilitate a broader discussion. A second objective you have in opening up a discussion of spiritual-psychological experience  115  during admission is modeling that this type of conversation is available to the Patient should they choose to pursue it. You find that the conversation develops depending on the Patient's interest at that time; it may develop immediately, you may refer the patient to an alternate source to explore their spiritual-psychological experience or you may return to the conversation at a later time. You feel strongly that the professional needs to be flexible regarding the patient's needs. In your experience these needs are very diverse. The patient may need you to address only physical needs. They may resolve personal issues with family members or friends with little professional input. The patient themselves may initiate a discussion. Finally, they may choose not to address their spiritual-psychological suffering. Further, your ability to comfortably explore issues with them, to refer to other team members or to other professionals may also be required. You find that when and if the patient is ready they will participate in discussion concerning their spiritual-psychological experience. In your view, it is the diversity of resources andflexibilitythat are the central advantages of the Team approach. On your team it's not only one person who plays the role of addressing spiritual-psychological needs with patients. Further, in having a diversity of resources on the team you have found that there is a possibility of referring a patient to a team member with a similar faith. You feel that effective use of the team approach involves communication among members regarding what's been raised with particular patients. It is this connection that you feel enables patients to continue their explorations with various members. On your team, if a patient connects with any team member it becomes that team member's "opportunity-slash-responsibility" to work with this person on their journey. The objective of the team as far as you are concerned, is to work together to build pieces of the process for each patient. It is by this means that you propose to facilitate the patient's journey. You feel that the central concern is drawing the patient's attention to their personal issues that need attention. Given social denial of spiritual-psychological experience, you  116  find that raising a patient's awareness may take a lot of work. Questions you use to initiate the discussion of spiritual-psychological experience include: "Are you afraid of death? of dying? What might your fears be? What do you think is going to happen?" Alternately you may make direct comments regarding specific steps a patient may take: "There might be something you want to say to your daughter" or "This might be a good time for the two of you to say things to each other which you might not have said like something as basic as 'I love you ". You 1  make a point of asking relevant questions to one or two patients per day and you find this is an effective practice in raising the issues with patients. Also of importance is your ability to convey your personal comfort in both raising issues and exploring them with your patient. In modeling your personal comfort you perceive that you give the patient freedom to explore their issues. If you find that a patient is resistant to exploring the psychological-spiritual dimension you may make a referral to a Pastoral Care Worker. Alternately, you may find that you need to be directive with respect to what the patient needs to explore. "It's my impression that there are some issues here and it might be important for you to spend some extra time with....". In your view it is the basic listening skills that are the central means of incorporating the spiritual self in helping. You focus particularly on observing, that is using your eyes and ears before you speak to your patient. You value the basic listening skills in part because of the diversity of your patient population; "multicultural, multi-faith, multiconfusion...we've got all of those". Further, you find that it is necessary to be open to the patient's spiritual understanding whatever that might be, hence again the value of basic listening skills. Conveying your personal availability to meet your patient's needs is another important aspect of care in your view. In the second interview you commented that you find that personal attitudes affect care at the bedside.  117  It really is the glass of water, "as much as you have done it unto one of these you've done it unto me". It's important. And sometimes it's that simple and sometimes it is getting somebody a glass of water and saying that's as important right now as it might be were it some complex IV medication that you need a medical degree for. This is the ethical principle of fidelity as you see it and it is expressed in steady comrnitment and compassion for people regardless of their condition or social status. You find that it may take the form of simply asking "Do you want to talk? Is that what you need". In general you feel that the professional needs to be on guard against assuming that the patient is there for the professional's purposes. The approach you prefer is supportive of the patient's working out their needs. The professional is in a service relationship to the personal process of the patient's. Related to this is what you perceive as the professional's healing agenda. In your view, though a professional's objectives and intentions may be based on prior experience or understanding of the patient's needs, you sense that their actions can interfere with attending to the client's journey. You feel that effectively communicating the patient's condition to them is a responsibility of the professional. "Making sure that people understand their options, understand the course of the illness and appreciate that within the limits of time and resources they know what is available to them". To achieve this you feel that awareness of the language you use is necessary. You avoid jargon, and you make a point of checking back with the patient regarding the information you've given to ensure that they've understood. Further, you are aware that when you speak your patient may have barriers to listening. In your experience the barriers may have to do with anxiety or novelty. You feel that in having an awareness of barriers to communication and exploring that issue if it is necessary, you strengthen your ability to communicate. Finally, youfindthat the combination of an attitude of acceptance, the ability to address physical pain and the ability to listen are the means by which psychologicalspiritual healing can be brought to your patient. In your experience, an environment that ehcits a sense of time, quiet, reflection and waiting are conducive to meaningful discussion.  118  You make a point of sitting down during hospital rounds, you consciously use eye contact and you ask permission to sit on people's beds. In your view these are concrete means of incorporating the spiritual-psychological dimension of treatment. You also don't wear a lab coat. For you this is an obscure yet meaningful way that you incorporate the psychologicalspiritual dimension in treatment. You feel that the lab coat is a symbol in society. In your experience, when you take off your lab coat you are more personally vulnerable to your patients' needs.  Interview #2: The Integration of The Spiritual Self in Helping Professions Is About Transformation Drawing On Deeply Personal Resources This theme reflects the Co-researcher's experience during the interview of working to convey an understanding which is more deeply known than it is articulated. The Coresearcher indicates that the incorporation of the spiritual self in working is sourced from profound personal experiences. The interview was very taxing for the Co-researcher. At times the material of the discussion produced a sense of risk-taking because it was very intimate and it may be perceived as somehow questionable. "I've told very few people this story because I don't know how to explain it and's such an intimate story". A related part of the struggle was a sense of having too much material to present. There was also a sense of difficulty in communicating how the spiritual self was connected to the process of therapy. "You know it's very very hard to talk about this". Articulation was one element of the difficulty. "You can see as I struggle here in this interview, I can't even articulate my frame". The Co-researcher frequently commented on a sense of rambling, repetition and feeling lost with respect to what direction to take. It was conceived that this difficulty arose as a result of not having previously articulated it in any cohesive sense. There was also a sense of lacking  119  vocabulary for conveying the understanding. "We've developed a vocabulary in a traditional sense. For example if a person is a Christian or a Buddhist, they can use the vocabulary of their religion to talk about it, but I think that for those of us who experience it outside of that sort of structure it's much harder to talk about it". On the other hand, the Co-researcher was enthusiastic about participating in the interview and was prepared to do the hard work of conveying an understanding of how the spiritual self is incorporated. "You know, it takes me a while to warm up, but (laughs) because I see it and it excites me, because I know it's true and it helps me to name it, because so often we keep these things silent, or we keep them in separate compartments". Stories and examples were ultimately found as the most expedient way to illustrate the incorporation of the spiritual self in therapy. There was no shortage of illustrations "I have so many examples and stories flying through my mind". These stories were in part highly personal spiritual experiences, some reaching back into childhood. Of these stories it was noted that they "have had a profound effect on my life and I think they literally affect my work every day".  SpirituaUty This theme considers the nature of spirituality. SpirituaUty is not contained in organized religion. It can exist there, but it is not contained there. It can also exist outside of organized religion. " One of the wisest people I ever knew was an old alcoholic bum who probably had grade two education.... he was a dear dear teacher of mine". Ultimately there is no distinction between spirituality and secular life. "They're one" "There's a spiritual element in everything. There's no distinction between spiritual and secular  120  life. I see that continually when I'm working with clients struggling with issues". The pursuit of meaning and making sense of life is a universal human need. SpirituaUty however has more to do with being than it has to do with meaning. "Can we go to that spot where we just are. Can we celebrate our aliveness". "To me that's spirituality, it's just isness, you're just, you're there". " I think spirituality has to do with an acceptance of what is. Horror, despair, pain, joy, dancing, celebration, young things getting born, things dying". Spirituality also has to do with knowing that there's something bigger. "AH you have to do is let the bigger picture happen and it's really nothing to do with you"" People say this again and again 'Gee it was nothing to do with me' Christians call it grace". Finally, spirituality is important. In the second interview the concept that spirituaUty has more to do with being than meaning was discussed further. "That is why it's often difficult to articulate it because it's a way of being in the world rather than a series of intellectual concepts....I think if a person is truly on a transformative journey...they get to the point where they suddenly understand what being alive is. They get into that sense of 'I am and I'm alive it's a very profound place but 1  it's a place of relatedness to their own life and the life of the world around them, it's not just a construct in the head. I have watched people move to that place and that's a place where I think a huge shift happens". Transformation's Three Elements This theme considers the three elements of transformation: getting in touch with one's suffering, being open to something bigger and transformational change. The three are in a complex relationship which is at once distinct and integrated. "Allowing oneself to experience one's own suffering can lead one to becoming open to something bigger". Being open to something bigger is a part of transformational change  121  and it continues in the ensuing life experience. There is however no causal relationship among the three elements. Suffering. Suffering is not the exclusive experience of victims of abuse. "Suffering is a part of being human, part of being alive. I think we all suffer". We have the option to avoid suffering by running from it. Facing suffering however is necessary for change to occur. I have noticed that when people are stuck in their process it's because they don't want to suffer and so they block themselves off from the suffering....They get into 'everything is nice , 'everything is fine 'everything is good', and they don't allow themselves to experience the depths of their own pain. I think in a way it is necessary. Maybe what's necessary is to really get in touch with it and allow yourself to experience it rather than try to avoid it. So, to go through a transformation process you have to experience where you are suffering and get in touch with that. 1  1  Further, the Co-researcher noted that "There can be some profound learnings from having to go to the edges of your life and beyond, and to have to go through those very very dark places". In the final analysis, the pain of suffering may never end, it may only be experienced differently. "You learn to be in a different relationship with your suffering and it doesn't take up your whole sky, like it does at first". The torture and abuse of some clients has been so great and they're in such pain that they question whether there's a reason for living. "Many of our clients were so abused that they can barely function now as adults". Some clients die in that place. The experience of despair at "the bottom of life" has many different forms. It may take the form of invasive flashbacks. It may be characterized by a carelessness about living or dying, perhaps even satisfaction at the prospect of death. One may be emotionally, physically, mentally and spiritually exhausted. There is a sense of emptiness and numbness to hved experience. One is disconnected from one's physical or personal reality.  122  Grappling with the question of whether to continue living can appear pretty crazy for a while. People deserve respect in coping with their woundedness. Respect is warranted also when people become stuck in the role of victim. In the second interview the Co-researcher went on to discuss that utter emptiness is one of the elements that contributes to becoming open to something bigger in the experience of transformational change. It is possible to be utterly empty and not be open to anything else. It is possible to be utterly empty and die. What's the difference between those who, not...just those who live, [but] those who transform and those who die. It's not [that] the person who died was a bad person or didn't try hard. It's nothing to do with that....I no longer judge suicide as I used to. I take a stand for life. But I no longer judge [suicide]. Considering those who transform the Co-researcher commented: " Something bigger happens at the point of emptiness and total letting go" This is the point of entry to the next sub-theme. Open to Something Bigger. 1. Something Bigger in Therapy. When change happens in therapy it's nothing to do with the therapist or client, it's something bigger than either person that happens. Healing is about opening up to that something bigger. From the darkest places of experience whether they're painful flashbacks or childhood memories, if one can be open to something bigger then perhaps something can happen. "I think it is a bigger's a possibility of something you can't see right now". Without that something bigger there would be no point in doing therapy. There is something bigger that directs the process of therapy. This intra-personal knowing that there's something bigger in therapy can't be communicated. It's not simply a form of realization. "What I've noticed's not that you find it, it's not that you go and you read the right books and you talk to the right people and you pray the right prayers and you find it. It's like, it finds you" People  123  need to know it and they may know it before coming to therapy. A person needs to be open to spirituality, to the something bigger. Unless we can be open to something more fluid we can become really stuck in our experience. Without it it may be too hard for clients to stay alive. Being open to something bigger is characterized in part by relationship to the diversity of experience in life. "I see so much despair in the world and I also love celebrating life. And, you know, to me it's worth it staying alive". "We can be in our despair, we can be in our joy. Healing's not about being happy all the time". It also creates freedom in living. " I mean I think we have to be curious and we just have to look on life with a certain sense of curiosity and wonder, and a letting go...that's when something happens". During the second interview the great difficulty of describing the experience of something bigger was reviewed in light of trying to discuss something experientially known which is lost in cognitive and theoretical discussions such as the present one. "It's so hard to describe what happens". The power of stories to convey the experience was discussed. The Co-researcher noted also that the phrase "something bigger" comes from clients who often name it in their reflections on the process of therapy and their experiences of transformation. It was noted finally that the something bigger is expressed in various religions but is difficult to express outside of such frameworks of understanding. 2. Unknowing A part of being open to something bigger is recognizing one's unknowing in the face of unhmited possibilities. Unknowing arises in relation to many issues; the resolution of personal pain, the meaning of suffering, the experience of healing, whether transformation will happen, even the right time for termination of therapy. "A client will say 'will my pain ever end?' and I'll say 'I don't know' and I don't know. How can I say?".  124  A part of uriknowing is recognizing one's limited capacity to judge people or circumstances. This unknowing includes whether different types of therapy are beneficial or what other people's experiences of things are. Other people's decisions are a factor of their process which falls in the domain of my unknowing. "I can't judge where someone should go, they go and I'll walk with them. That's what it's about". Each person needs to work through their possibilities for themselves and make their decisions based on that. 3. Client and Therapist as instruments in a bigger process: Letting go The moment when the Therapist and the client become completely immersed in the process of therapy is a spiritual moment. I think there are moments in therapy where the Therapist literally gives himself or herself to the client and it's a spiritual act. It's where they are truly the vehicle and they function as the vehicle. And the client uses the Therapist in that way and through using the Therapist transformation happens....That's the moment, that's the spiritual moment that happens when both the client and the Therapist let themselves go and open the way to something bigger happening. Something deeper happening. Where you get in touch with the...central core that you were out of touch with beforehand. Or > something...comes in that wasn't there before. In this moment both the therapist and the client are instruments of a bigger process. "I'm not so sure it's how we play the instrument, it has something to do with allowing ourselves to be played" "It really has nothing to do with either of you. It's something that's a lot bigger". The process of becoming instruments is not conscious and cannot be willfully created. The client loses their sense of self and the Therapist is similarly consumed in the process. In the second interview the Co-researcher discussed a sense that what influences the process is something bigger than what a purely visual or cognitive summary of the encounter could convey. The Co-researcher illustrated the experience with a psychodrama in which the Therapist and the protagonist exercised deeply unquestioning and unhesitating availability to the protagonist's sense of what was needed for healing. As a result to put it simply, something bigger happened in the psychodrama than could have been anticipated. 125  The healing effects of the experience were profound, exceeding those commonly experienced in therapy. Of this psychodrama the Co-researcher stated that the protagonist "could never have gotten there through talk therapy or any other way". The experience is comparable to the athlete's or artist's experience of letting go. The artist might say "I let the picture paint me. I didn't paint the picture". The athlete might say "I let it happen. I got myself out of the way". One may in a limited way compare this to being intuitive in therapy "but for me I see that as a spiritual process". Getting yourself out of the way as the Therapist is the essence of therapy. The Therapist's ability to become an instrument of some bigger process eventually happens automatically and spontaneously. "But there's a way of letting go and being absolutely and utterly there with that person". This is an art form, not just a technique. It seems counter-intuitive to say that letting go is when the best work happens. Not letting go is related to exhaustion at the end of a working day, while letting go is related to increased energy. "Effective helping is absolutely being there, being protected and being open to the larger possibility. And just being the instrument". Transformational Change. The Co-researcher described transformational change in relation to the therapeutic process as follows: It's almost like there's an energy present...I don't understand anything about radio waves but I understand that they're all around us and if you have the right machine, the right little box that you turn on, they get turned into sound, but right now I can't hear them. O.K. Well I've noticed in therapy sessions....I don't know how to talk about this without sounding crazy (pause) A client may struggle for years and years...with something and all of a sudden one day they're in a session and something happens....They will label it afterwards as a transformative moment in their lives. Other times people won't be able to label the moment, but they'll say that something happened. It's like they changed their relationships with the world. And it's like their sense of self... becomes open to a bigger possibility, and it's like the bigger possibility isn't just an intellectual concept, it's a something. And it's a something that happens and that carries them. 126  Transformational change is profound and inexplicable. "They make a decision for life even though they can't explain to you why". Following the moment of transformation one moves on and is never again the same. Even years later one can refer to that moment of transformation and they can continue to experience its influence in their hves. The experience is highly personal, and one risks appearing crazy at an inter-personal level when they refer to this change. Transformational change is related to experiencing one's despair. Transformation is about allowing yourself to go through the fire of facing your pain on a healing journey. Essentially the movement is from a place of "emptiness, or despair, or terror or constriction or fear...and the way to this other place". Transformation is coming to the point in your life when "you choose life or, it's not even choosing life, it's letting life choose you". It goes deeper than a Gestalt release of feelings. The Co-researcher refers to it as a holy moment, "Getting Godded". One has no influence regarding when or where transformational change will happen. It can be accessed through formal religion or by other ways. It can be profound or comparatively insignificant. "It can be the littlest thing that suddenly makes the difference...someone smiled at you. Or someone gave you a glass of water". The transformational moment is related to readiness. But you can spend a hfetime and not be ready. How to get ready is unknown. Coming to the point of transformation is a spiritual journey. "I don't know how else we can do that". 1  It is possible for the therapist to know when transformation happens for the chent in  the moment in the therapy room. It is very common in therapy. "I've seen it hundreds of times in working with people". Further, the cycle of transformational change is the same. One moves from a place of death and despair to being somehow met by something greater and then undergoing profound personal change. "It's the same thing, there's no difference in any of those examples, there's a common theme through here". The cycle of transformation is compared by chents to the  127  Christian expression of being "born again". "Because if you decide to live after you've been in a place of death, you are born again". Practice This theme considers the components of practicing therapy which incorporates the spiritual self. The topics of consideration include; the therapy, clients, the therapist, team support, training, and professional limitations. Therapy. Experiencing the despair of "the bottom of life" happens often in the process of therapy. "I've been in that place many many times with clients. And also many many times with staff as they struggle through the despair that you can't help but feel when you work with horror and trauma day after day". Therapy is "a spiritual process and a transformative process". Awareness of the spiritual is experienced daily in interaction with clients and staff. Therapy can lead to transformation. Transformation is what people are looking for when they come for therapy. The capacity to work with victims of trauma is underlaid by personal belief. "I really do have a belief system that no matter where a person came from they can heal somehow". To work with victims of trauma one must find some sense of meaning and making sense out of life. It is necessary to be able to address questions of life and death. In fact, working with trauma necessitates a spiritual perspective. "I don't think I can work with victims of trauma without having a sense of spirituality". Without spirituality working with trauma would lose it's value and the Therapist would risk falling into despair. "I think I would give up and pack it in and go home". Therapists working with trauma are often spiritual people. "Every Therapist in this agency who works with victims of trauma I would say is a very spiritual person.... Most of them can articulate it in some way. Some are more traditional, some are not traditional". In the second interview the Co-  128  researcher commented further: "Without the knowledge and belief that people can transform I could not bear to hear that level of pain everyday". The theoretical approach to helping is infused by personal experience. "I can't separate my theory from my life". In general, Gestalt, Psychodrama, and Jungian are suitable theoretical approaches. However, theory amounts to people's constantly changing ideas or awareness regarding how things work. A personal theory reflects this understanding. "My to create a stance where I'm open to any possibility at any given moment". The approach of the workplace is feminist. The learning that arises in the counseling relationship then is mutual. "We don't see ourselves as people who know it all ....They're our teachers to, and we walk on this journey with them". The Skills used in incorporating a spiritual dimension in therapy are the basic counseling techniques. Using language the client can relate to. Not imposing the Therapist's views. The Therapist also needs to use and be respectful of the client's spiritual framework in discussing their experiences. The use of symbol and ritual is also quite valuable. Theory, technique and practice are necessary though they are initially incorporated by the Therapist with too much consciousness. These skills need to become automatic so that the Therapist can let go and be present with the client. The acknowledgment of one's unknowing is also necessary. To this end, don't tell clients that transformational change will happen because it is unknown. Even with a client who's looking at the possibility of dying you can't explain why they should stay alive. " 'I can't give you a reason to stay alive, and I don't want you to die. And I'll sit here with you and you can tell me about your pain.' And I'll just stay there with them, but I can't give them a reason to stay alive. That has to come from somewhere else, and again and again it does".  129  The Therapist's ability to be present to the chent is essential. Contact is the place where transformation can spring from. It is uncertain whether the incorporation of the spiritual in therapy can be taught because it's not truly a technique. "I think [it's] more to do with the quality of being with that person, with a connection to that person...which somehow creates a bigger reality". The Therapist's presence with the chent means simply being with the client in whatever the chent brings. "The technique has to do with going into whatever reality the client has and taking it seriously". Presence also has to do with accepting the client's struggles with despair and their questions about death. "Effective helping is being there where the client is, being totally present to the client with everything that's in you and being open to any possibility that might happen". During the second interview the Co-researcher underlined the fact that the transfomational therapy discussed is related specifically to the needs of the chent population. "We don't do....light counseling. It seems to me that lighter counseling is different". This was not to suggest that spirituality has no place in the context of lighter counseling. Chents Chents have personal wisdom whereby they know what they need in order to heal. Of one psychotic client the Co-researcher commented " She understood some things [about her needs] that I think a lot of medical people, a lot of psychiatrists don't understand". Understanding that client's have wisdom regarding their need for healing is seen repeatedly in practice. "I find that again and again in my clients and in the clients of Therapists that I supervise that somewhere, at some level they know what's true for them and they know what they need to do". Something about what a chent is doing is the key to what they need to do for healing to occur.  130  The community in general and clients in particular aretalkingmore about spirituahty. chents are more and more often requesting the use of ritual and ceremony in therapy groups. Chent stories of spiritual experiences are common. During therapy some may recall spiritual supports from childhood. "There was a guardian angel there, or there was this beautiful lady and she smiled and she reached out her hand and she helped me through" Clients develop rituals or ceremonies or call on spiritual guides or figures to aid them through difficult aspects of their healing process. "Again and again they will talk about a presence of something bigger than them that went to protect them while they did that". These experiences are very meaningful to clients. Chents are vulnerable to a sense of being perceived as crazy when they relate these stories. "They're afraid of being told that they're hallucinating". The Therapist. Therapists without a sense of spirituahty are missing something important. "They're doing therapy from a very tiny context. They're doing very tiny therapy". During the second interview the Co-researcher commented further: I've noticed that Therapists who don't understand this mainly do sort of a pure cognitive therapy. Which is fine. Goal setting and problem solving. But they don't work at the level of transformation, because you can' have to be open to this possibility. And once again I think you take your clients where you are and where you've been. If that's where you are in your life that's where you take your clients. One element of being able to be fully present to the chent is the Therapist's experience of the edges of their personal pain. "If you haven't had the opportunity to be brought to the edges of your own pain, how can you be there with your client?" Evidence of having been in this place is the Therapist's ability to talk about their experience in this deep place of pain. If the Therapist can talk personally about this place, they can also explore it with their chents.  131  Therapy is dangerous work. "I think we open ourselves to a lot of danger when we're in the therapeutic moment and we have to be very protected and not be naive". The Therapist needs to find a balance between being open and protected because the world is dangerous, and therapy is dangerous. "You cannot do the deeply spiritual work without being protected". During the second interview the Co-researcher commented in greater depth about being protected as a Therapist. As a Therapist, being hurt in the process of therapy is the experience of getting caught in despair. One is bruised or penetrated at the level of one's soul such that one's sense of aliveness and hopefulness, one's personal essence is undermined. If I'm getting hurt in a session, I literally can feel myself falling into horrible despair and hopelessness. I experience it as a sinking feeling. When I'm not getting hurt and I might be witnessing the same level of horror I'm coming from a place of knowing that a person can experience that horror and be O.K. But when I'm getting hurt I'm beginning to believe that no-one can be O.K.. We're all doomed and everyone's a torturer....You have to let go of that. You have to be able to see goodness out there too, and at the same time not be naive. One's personal spirituality is a unifying element of protection. "You have to consciously develop your own spirituality and come to understand what that means for you and develop your own relationship to it". The Therapist's spirituality is protective in numerous ways as indicated in the following discussion. The practice of centering through using ritual before and after clients is a central approach to being protected. "You take a moment or two before your session where you just sort of get quiet, you just sort of clear yourself and you get centered into whatever your place of centering is and you welcome the client into your therapy room from that space of being centered and...there's literally a protection". Before the client arrives the Therapist experiences "an opening to the client's presence. When the client leaves it's sort of a letting go, it's sort of a cleansing and sort of a blessing" The use of  132  personal rituals to bless clients who have committed suicide or been killed is also necessary. Centering through ritual is an individual process. Visualizing light around oneself, lighting candles, having a particular stone or crystal are all examples of the way one might get themselves centered in ritual. Centering is necessary for the purpose of being fully present to the client. The Co-researcher also observed that the Therapist is very vulnerable when they enter a session from a place of "ordinary reality", that is consumed in part with the business of daily living; phone calls, engagements, household and office tasks and so on. From this centered and protected position the Therapist engages the process of therapy from a position of "one step back". "Your heart is there in compassion for your client and your mind is there, and your soul is somehow protected". From this vantage point the Therapist is fully attentive to whatever the experience and process of the client is without being hurt by the client's sometimes horrendous stories, or vehement transference. "You have to sit in a different place with that and not take it into your soul". The experience of being "one step back" likely cannot be taught, rather it is learned through practice. "People have to practice it and practice it with intention. And I think if you don't you're in big...trouble with this type of work". Another element of being protected as a Therapist is practicing "balance" in work. This entails monitoring the number of clients one sees in a given day. Not working back to back sessions all day long. Not being seduced by a long wait list into getting overbooked. "You also have to take care not to develop a grandiosity to the extent that you think people need you. You're there, you're walking the journey with them. There's lots of resources around. You don't start thinking you're really important". In aid of this the Therapist needs to be able to be sick, take vacations and time out. "You let happen whatever happens and you get disconnected  133  from's nothing to do with you". Following the first interview the Coresearcher made a comment off tape to the effect that "my work is not my life". Finally, the Co-researcher commented on the importance of living life richly for the purpose of personal protection. Theater, drama, good books, people, children, camping, hiking, skiing all contribute to a sense of richness in life and protection in practicing therapy. "You need a lot of reserves in doing this type of work. You need to have experienced goodness in your own life. You need to have joy" The Coresearcher also highlighted the value of laughter. "You have to have a lot of laughter, more so than maybe most people have....And I think that's very spiritual to". Team Support. The ability to gain and give substantive support among staff members in dealing with the personal difficulties that arise in practicing therapy is necessary. Along these lines, supervision is an ongoing necessity. As an aside, the importance of support is a sahent issue for professionals who may be isolated in private practice. It's professionally necessary to be able to name and talk about counter-transferential experiences of despair. Accommodating this need can occur both for individual Therapists and as a team. For example, an open office door may be an indication that a Therapist is available to talk with another Therapist if they are needing support at a given time. At a team level also it is possible to incorporate the spiritual dimension using team rituals or bringing symbols such as things from nature, candles, poetry, stories and so on. Conversation about spiritual issues may also be beneficial. We talk about the spirit and we talk about darkness and we talk about falling into the pit and we talk about the horror and we talk about protecting ourselves and how we can protect ourselves and how we can support each other in this work. And we talk a lot about the concept of being instruments.  134  The team can also explore issues of hopefulness, triumph, meaningful experiences and so on. The effect of the inclusion of symbol and rituals in team work is an enriched working environment. Though the agency may be secular, the team can work effectively despite a variety of spiritual preferences among it's staff. Training. Therapy training falls short in its failure to explore deeply personal and spiritual issues with students. Instructors may do so in private conversations, but not in class where it's needed. The reason may be that there's fear of getting too much into feelings. The fear arises perhaps because of a sense of violating students, or that things may become too personal. Instead training focuses too much on head knowledge. Training for Therapists has to involve the whole person, "we have to be able to sit down and we have to not be afraid to cry, we have to not be afraid to experience all our feelings and to express them and not just stay in our heads". Training needs to address the issue of the Therapist's experience of dealing with despair on a day to day basis. "We hear the term burn out, but we're talking about something really different from burn-out and...we see burn out and we see what we call secondary traumatization where you're exposed to the horror, and what starts to happen to you as a Therapist. And how can you protect yourself. I think that's very much a spiritual journey". Training also fails to address the issue of transformation. This may be due to a lack of vocabulary or because it seems too intimate. Finally, it's necessary to teach the concept of the Therapist's use of the self as an instrument. This can be done through both modeling and instruction.  135  Professional Limitations. Psychology fails to really address experiences of transformation. The incorporation of the spiritual in therapy is often neglected in consideration of therapy. "So often we keep these things silent, or we keep them in separate compartments". Therapists may err in claiming that their chents are not ready for transformation when the question should be more inclusive regarding who is not ready. Further, Therapists often protect themselves from their chents by intellectuahzing issues and not facing them. At times treatment approaches can neglect an individual's personal wisdom for their healing. A course of treatment may even inhibit that healing process. The value of quick-fix therapies is also debatable. "I think you have to be open to possibilities, not deciding how the person should do, where they should go in how many steps". Whether the head knowledge gained in cognitive therapeutic approaches is sufficient for the client who has spent years "mnning on empty" is questionable. Therapy is not simplistic. Much research and work at the Universities is irrelevant to the practice of therapy. As a result the professional journals are for the most part of limited use to practitioners. The research work being done does not sufficiently explore the experience of being present to the chent. Laboratory studies fail to encompass the experience of real hfe such as is encountered in therapy. As a result many practitioners don't read the journals. The Co-researcher closed the second interview with a quote from the Navajo people which captures the essence of what can happen in therapy. " 'If you take one step towards the god, the god takes ten steps towards you*. I have seen that, that's the magic of the work. That's the something bigger". The Co-Researcher also gave the Co-Investigator a poem which is included as Appendix E.  136  Common Elements General Observations The Co-researchers have a strong awareness of the spiritual dimension in lived experience. They also have a lot of personal clarity about how the spiritual self is incorporated in helping. For both of them the recognition of the centrality of the spiritual self in change is continually reinforced in their work. For A this realization is the basis of a continued professional investment in incorporating the spiritual-psychological in treatment. B comments on how often the transformative moment is witnessed in the process of therapy. The Spiritual Self The exhaustive descriptions indicate that the spiritual self is an inherent aspect of our being. A states this specifically. B talks about spirituality as a quality that is universally accessible even though it may not always be accessed. They find that the spiritual self can be expressed within a search for meaning or purpose. A endorses the view that spirituality has to do with a pursuit of meaning and purpose in life's journey. Though B finds the search for meaning and purpose of less substance, B acknowledges there is an unavoidable personal question of meaning and purpose in working as a trauma therapist. Both also discuss that the spiritual self has to do with a way of being in the world. Spirituality as the experience of "isness" is more representative in B's view than the pursuit of meaning. A however also states that spirituality is "how you be" though this is not explored in depth. A and B describe spirituaUty as something bigger than present reality. A considers that the spiritual and the psychological are divided along vertical and horizontal planes though they may meet at some point as a result A does not distinguish them. B chaUenges the common distinction between spiritual and secular,findingthat there is no difference there. The extent to which the psychological and the secular are linked is  137  unknown however it is notable that both find such traditional distinctions of spirituality without practical value. Both A and B talk about the importance of connection to the spiritual domain. A describes this as connectedness to God or God consciousness. B talks about it in the necessity of being open to something bigger. For both of them this connectedness is related to health. A talks about spirituality as being expressed in relationships. This comment connects with B's discussion of the spiritual potential of the therapeutic encounter. Both of them emphasize the importance of the relationship between the professional and the patient or client for purposes of change. The interviews reflect the necessity of coping with existential aloneness. A states "We are alone" and explores our resolution of that aloneness with respect to suffering, healing and in a different way throughout the theme of the journey. B's discussion in the theme of unknowing similarly conveys an awareness of the fundamentally alone process an individual must work through in addressing their suffering. A's discussion of acceptance of life as a necessity for healing correlates with B's discussion of isness and being in the diversity of hfe. Suffering For A and for B suffering is a fact of human experience and while both express an interest in eliminating suffering, both simultaneously see that suffering is woven into the fabric of our human experience. For A suffering has to do with being disconnected from self, other and a higher power. For B suffering is described specifically with reference to abuse but it is also much broader than this. Examination of the nature and effects of abuse can demonstrate the lack of connectedness expressed by A . Thus the two views can be seen to be parallel. They see the experience of suffering in looking at one's death as potentially cathartic in the patient's or client's experience. A talks of facing death as precipitating an  138  appreciation for life. Similarly B talks about the "bottom of life", the point of utter despair and entertaining the possibility of death as the place from which something new may begin. B finds that there can be profound learning from addressing suffering while A discusses the peacefulness that is experienced in the resolution of suffering. These two views of the effects of addressing suffering are not necessarily inconsistent. They talk of the tendency they've witnessed to avoid suffering. A sees this as a result of social denial. B sees it as a desire to avoid personal pain. Both express the need to face suffering in order for change to occur. It is in facing suffering that both of them see a greater chance of recognizing the spiritual self and beginning a process of change. Change for both of them hinges on some form of spiritual awakening or awareness. Change Both Co-researchers indicate that choice is an element of change. For A change is manifest in the deliberate healing of relationships. Healing change has to do with resolution, a sense of purpose and connectedness. B takes the idea of choice in a different direction considering that change has to do with choosing life or with "being chosen by life". For B change to a new way of relatedness to the world is the potential outcome of transformation. An outcome having to do with relatedness then is also common to both Coresearchers. Both indicate the concept of a journey. For A this is a unifying central theme and is considered over the lifespan of the individual. For B the concept of a journey is less substantial, and it is experienced specifically in relationship to transformation. The Therapist's Self is Pivotal in Practice The Co-researchers find that addressing personal issues is central to the process of effectively incorporating the spiritual self in,working. Related to this, both talk about the need to work through personal issues that arise specifically in relationship to patient/client issues. A talks about working through personal issues to come to a place of bringing  139  compassion and spiritual-psychological healing to patients. B talks about the necessity of knowing the edges of your personal pain in order to be able to be there with your client. Both express a sense that at times their work is overwhelming. Both find that dealing with the dark extremities of their patients' or clients' lives is at times too much. B expresses further that this is a common occurrence in working with the given client population. They have incorporated the spiritual self in practice in response to lived experiences and their experiences with their patients or clients. Both express that spiritual experiences or commitments that were existent prior to their present vocations continue to hold profound influence on their approaches to working. For A this was a commitment to a Christian way of life, for B this was exposure to spiritual experiences of transformation. They find that the necessity of incorporating the spiritual self in work is continually reinforced in their interactions with patients or chents. For both of them availability or presence to the patient or chent is the central skill of effectively incorporating the spiritual self in practice. A focuses on expressing personal availability to the patient. A values the ethical principle of fidelity to the patient and outlines specific actions and manners whereby availability is communicated to the patient. B underlines the Therapist's practice of presence with the chent. Both Co-researchers make reference to the proverbial offering of a 'glass of water to the patient or chent. In A's 1  discussion this was an indication of the depth of availability to the patient's need. In B's discussion the glass of water illustrates the simplicity of what may precipitate transformational change. Even for B however the glass of water indicates a depth of presence of the professional in relationship to the patient or chent. The Co-researchers find that they are continually confronted with the spiritual dimension of hfe in their work. B comments specifically on seeing the spiritual side of hfe everyday in working with staff and clients. A comments on choosing to be open to the bigger dimension of patients' suffering than that captured in the medical model.  140  Both of the Co-researchers have developed their own approaches to their work. A has expanded the medical model to incorporate a spiritual-psychological dimension. This expansion has been based on the perception of the spiritual-psychological needs of the patients. B similarly has become aware of the limitations of models of counseling and while using these models has added a personal theoretical stance of openness to possibilities. By this stance B encompasses spiritual transformation in the process of therapy, and recognizes that therapy is a spiritual process and a transformative process. The Co-researchers express that the absence of the spiritual self in their work would render their work without personal value. A talks about being confined to a medical model approach and that work would become simply a "job". B talks about packing it in and going home because there would be no point in doing the work. Both interviews indicate in summary that the personal, professional and spiritual are closely intertwined. They discuss personal practices related to their spiritual lives. For both of them a rich life aside from their work is very much enjoyed and a source of spiritual sustenance. They also practice private meditations. For A this practice is a part of personal spiritual growth. For B this practice is a part of being protected and preparing for the coming of the client. Both express the personal enrichment that is related to incorporating the spiritual self in working. A talks about a personal sense of resolution, meaning, value, satisfaction and pleasure. B talks about the impoverishment of therapy and the hmitations of Therapists that neglect the spiritual element of treatment. Issues of Practice The Co-researchers emphasize the need for flexibility with respect to the patient's needs. B expresses this in the commitment to the client's leading the process. A talks about the range of possible needs of the client's and talks about not imposing a professional agenda for healing or change.  141  They discuss that it is the basic listening skills which underlie the incorporation of the spiritual self in practice. Both emphasize an awareness of using language the patient or client can relate to. They also emphasize the use of the patient/client's spiritual frame of reference. They are deeply respectful of the patient's or client's lead through their process whatever that might or might not be. A discusses the professional's serving role in relation to their patient's needs. B talks about trusting the client's personal wisdom regarding their need for healing, and about taking the client's reality seriously. A perceives a singular capacity of the discipline of Counseling Psychology to recognize spiritual psychological pain. B's observation that therapy is a spiritual process and a transformative process supports A's comments by suggesting that therapy is a process of becoming attuned to spiritual experience and change. A discusses a sense that society denies the spiritual dimension of experience. It is possible that this observation is linked to B's repeated observation of the client's sense of possibly being perceived as being crazy in discussing their spiritual experiences or their experiences of transformation. Both discuss that the incorporation of the spiritual dimension is a mutual experience for the Professional and the patient or client. A talks about the mutual sense of meaning that is gained in the exchange. B refers to the feminist orientation of the organization and the fact of being teachers to each other. The interviews reflect that the effective incorporation of the spiritual self in practice requires time and experience. The need for mastery of the skills of one's profession is discussed by both A and B . Both comment on the awkward behavior of the novice in trying to get everything justright.Maturity is expressed for A in the ability to be comfortable being fully oneself in the professional role and B talks about getting to the place of being able to let go.  142  Limitations to integrating the spiritual self The Co-researchers discuss a sense that some professionals may be unable to incorporate the spiritual self in working. A discusses this with reference to some people being unable to see the importance of the spiritual-psychological healing in treatment or for the patients. B discusses this with reference to the professional taking the client to the place where they are. They also talk about the limitations of their professional models as a result of not including the spiritual. A talks about the medical model as being hmited by its exclusive focus on the physical component of disease and cure. B talks about the tiny context of therapy which is practiced by therapists without a sense of spirituahty. Both address that other approaches work to a greater or lesser extent, however both find them insufficient to the needs of their patient's or chent's. A's experience that treating pain does not always relieve suffering, and B's observation that a step by step approach to therapy does not alleviate years of mnning on empty demonstrate the insufficiency of some approaches to treatment of patients and clients. A and B describe how their incorporation of the spiritual self in practice has to do specifically with the needs of their patient or chent populations. Both Co-researchers find that their patient or chent populations are wide open to the possibility of spiritualpsychological exploration, though this is not a universal rule. A talks about the relevance of a medical model approach to treatment with many patients. B talks about the how the spiritual dimension may be less used in more common therapy practices. Training They have found that their training focused largely on academic knowledge, and both found that their training inhibited the development of the spiritual self. A speaks of the experience of socialization in a model that precluded personal growth even though this was counter to a personal value system. In consequence A's incorporation of the spiritual self has been very much a part of a personal and professional journey. B discusses the  143  neglect of counselor training in raising and addressing student issues of personal growth and development. A feels the neglect of a personal growth dimension reflects the Umitations of the medical model. B expresses that the university program is inhibited by the risks involved in exploring the personal dimension of students' experience. The Co-researchers observe that training in incorporating the spiritual self in practice may be problematic because it is in many respects understood experientially. Both however also make suggestions regarding the type of training needed in their disciplines. A expresses that training in the Physician-patient relationship needs to beginfromday one in medical school and needs to encompass learning about the nature of persons and communication skills. A talks further about using modeling to teach residents about interview skills and the integration of the personal and professional. B also talks about the importance of modeling as a method of training. B feels that instruction is needed in transformation and the concept of being instruments in the therapeutic encounter. Additional Elements These additional elements are expressed by one or the other Co-researcher yet they warrant attention because they express the experiences of the Co-researcher's in their particular professions. For A the team is an essential means of incorporating the spiritual-psychological approach to treatment due to its strengths in diversity andflexibility.If a patient connects with a single team member that person will-take the opportunity of attending to the patient's journey. Otherwise the patient's process is shared among team members who co-operate in working with aspects of the patient's journey and hold a common focus on spiritualpsychological caring. In A 's role as Doctor, it is essential to be able to communicate availability to the patient for both physical and spiritual-psychological needs.  144  For B the use of the therapeutic team is an essential means of individual and group support in coping with the Therapist's personal issues which may arise around working with this client population. B comments also that psychology as a discipline fails to address the experiences of transformation. Further, current research is not representative of the real life experiences encountered in therapy and is therefore of only limited clinical use.  Statement of the Underlying Structure Introduction Colaizzi (1978) identifies the final step in Existential Phenomenological Research as the attempt to make as "unequivocal a statement of identification of the fundamental structure as possible" ( p. 61). Three steps have been taken to elicit the fundamental structure of how the spiritual self is integrated in the work of helping professionals. The first step is a summary of the overarching themes of integrating the spiritual self in practice. The themes are pivotal to the Co-researchers integration of the spiritual self in practice. Secondly, there is a summary of the discussion of the common elements of the two exhaustive descriptions  Interview #1: The Integration of the Spiritual Self in Helping Professions is a Journey The incorporation of the spiritual-psychological in practice has to do with connecting to cut-off relationships in a journey of resolution and healing. Spirituahty is inherent in our being and this is expressed in our existential aloneness and in.our experience of relationships. The nature of our connectedness to self, other, and value, meaning or some Higher Power is the basis of our suffering, resolution and healing. Suffering is characterized not only by pain but by being alone and cut-off from relationships. The pain of suffering is excmciating and can precipitate the desire for death. Facing suffering is the beginning place of the journey. Facing dying brings us in touch  145  with the journey by connecting us with the spiritual-psychological dimension of living. This awareness creates the possibility of resolution and healing. Healing is a choice and has to do with acceptance of life. Healing is dependent on whether something is resolved or resolvable. If something remains unresolved it leads to suffering, otherwise healing can occur. The spiritual journey of incorporating the spiritual-psychological in working is multi-dimensional and is experienced socially, professionally and personally. The dimensions of the journey are interwoven. Following is a summary of the journey in six parts; the social journey, the journey of the medical model, the patient's journey, the professional journey, the team's journey and the personal journey. These illustrations of the journey are interwoven, each affecting the other in the areas of struggle and progress towards greater integration. In this sense the journey is dynamic. The Social Journey. Society is afraid of death and therefore denies death and spiritual-psychological experience consequently increasing a social sense of aloneness that is, suffering. Society is however showing signs of longing for change yet change must occur at a cultural level. Socially sponsored research into the spiritual-psychological dimension is indication of interest in the spiritual-psychological dimension of experience. There are also professional groups interested in promoting social change. The Journey of the Medical Model. The medical model concurs with the social denial of the spiritual-psychological dimension in its exclusive focus on physical treatment and the pattern of socialization in its training programs. The socialization of the medical model is sufficiently influential to render Doctors unable to connect comfortably with themselves, other or some Higher Power when they are in their professional roles and addressing their patient's experiences of suffering. There are indications that the medical model is beginning to consider a broader approach to treatment including some current research and training which considers the  146  spiritual-psychological dimension of the relationship between Doctor and Patient. Current research can address the hmitations of the medical model with respect to the spiritualpsychological dimension of treatment. The Patient's Journey. Social denial renders patients unable to identify their spiritual-psychological suffering as such. As they face their deaths, patients are brought in contact with the spiritual-psychological dimension of their experience. For patients, healing is experienced in resolving relationships to self, other and some form of meaning, value, purpose or Higher Power. The Professional Journey. Some areas of medical practice must address the issue of Patient suffering as well as the treatment of pain. Patient suffering is witnessed repeatedly and has led to an individual professional conviction regarding the necessity of incorporating the spiritualpsychological in working. Integrating the two approaches to treatment; the traditional medical approach and a spiritual-psychological approach, is a challenging professional choice. It is also problematic with respect to time management. The effective incorporation of the spiritual psychological dimension of treatment takes time and experience. It is effectively incorporated in a combination of practice and research. The objective of treatment is to address the whole person of the patient. Bringing spiritual-psychological healing to the bedside is a unique skill in treatment. The patient-Doctor exchange becomes deeply purposeful and meaningful as the Doctor opens himself or herself in availability to whatever the patient's needs might be. The effect of this approach to medical practice over the long term can lead to change socially and in the medical model. The Team's Journey. Healthcare providers in general are not providing sufficiently for patient suffering. The incorporation of the spiritual-psychological dimension of treatment using a team approach is not documented. It is intended that the team will work together in a co-  147  ordinated way to address Patients' on their journey of spiritual-psychological suffering. The multi-disciplinary team is in a growth process. It is working with inter-personal dynamics as well as skill development. The team principally needs to learn basic communication skills of observation and empathic questioning and challenging. The team members have varying abihties to incorporate a spiritual-psychological approach in treatment. Differences are due to awareness, maturity, training perspective, and willingness. The team is an essential means of incorporating spiritual-psychological treatment in the hospital setting due to its capacity for flexibility and diversity in addressing both Patient needs, and the limitations of time and the institutional setting. The Personal Journey. The incorporation of spiritual-psychological treatment spans a hfetime of experiences including childhood, religious, training, and professional experiences. Spiritual-psychological treatment continues to be a long-term developmental process of incorporation. The work is demanding at a personal level as one is touched deeply by patient experiences, and one is challenged to work through personal issues and personal growth. The effects of the incorporation of the spiritual-psychological dimension however are a personal sense of meaning, purpose, and connectedness. This professional work transcends the ordinary role of the Physician and its influence is pervasive in practice. Personal comfort with spiritual-psychological experience is essential in facilitating the patient's freedom to engage a similar journey. Personal practices of connectedness in relationships to self, other and God are elements of hved experience. Bringing the patient's attention to their spiritual-psychological journey is the primary task of incorporating the spiritual self in practice. To raise the patient's awareness, the professional communicates availabihty to the patient for this type of exploration by raising issues, practicing a manner of availability to the patient's needs and using basic hstening skills. Admission is thefirsttime questions are raised. The given patient population are at a point where the journey is immediately relevant in their hves. In  148  consequence, the medical practice of the Co-researcher would be severely lacking without the incorporation of the spiritual-psychological journey. The effect of incorporating the spiritual-psychological journey is mutually beneficial as both the patient and the professional are moved in their encounters with each other's spiritual-psychological journey of connectedness and resolution.  Interview #2: The Integration of The Spiritual Self in Helping Professions Is About Transformation SpirituaUty is the experience of being, it has to do with isness, a way of Uving in relation to the diversity of experiences in life. "There's a spiritual element in everything". Therapy is a spiritual and a transformative process. The expression of the incorporation of the spiritual self in practice can be captured in only a limited way because it is a personal and experiential knowing. Nevertheless, the integration of the spiritual self into helping has to do with working with the constant and immanent potential of transformation in therapy. Transformation has to do with facing one's suffering, being aware of something bigger and opening oneself or being opened to that possibiUty. Being open to something bigger occurs for both the cUent and the Therapist. Being open to something bigger as a cUent entails sitting in the place of suffering and being somehow met by something bigger. Being open to something bigger as the Therapist entails thoroughly trusting the cUent's process and knowing that something bigger can happen. The Therapist is deeply present to the cUent. The Therapist also trusts the client's personal wisdom in their process. From the client's and Therapist's work of being instruments opened in a therapeutic process, transformation can arise. Transformation also occurs in diverse circumstances. Transformation is profound, inexpUcable and life changing. The Co-researcher finds it well expressed in the phrase "Getting Godded". Therapy is about journeying to a place of spiritual transformation. It is transformation rather than healing which is descriptive of what change is about.  149  Therapy is an art form which has to do with letting go. The work of therapy is personal as the Therapist remains open to bigger possibilities in terms of theory, the course of therapy, the client's process, and the unpredictable nature of transformation. The work is premised on a belief in the client's potential to heal regardless of the circumstances of their lives. This belief system is a necessity in working with victims of torture and trauma. Further, therapy without spirituaUty is extremely limited and would be unacceptable to the Co-researcher. Protection as a Therapist is a necessary precaution against secondary traumatization and burn-out. SpecificaUy it has to do with the Therapist's experience of protection against the despair which may arise as a result of counter-transferential issues with a client. Protection is based on a conscious development of one's spirituaUty. In practice some steps that the Therapist takes for protection have to do with rituals of centering, welcoming and releasing cUents before and after their visits. These rituals are uniquely developed by each Therapist and are characterized by a clearing away of the ordinary business of day to day living. The effect of practicing protection is that one can connect with one's client from the position of "one step back", that is, fuUy present to the cUent yet also protected in one's soul. From this vantage point the therapist is free to "sit in a different place" with a client's pain. They can be with the client in their pain yet not be consumed with the despair of that place, "knowing that a person can experience that horror and be O.K.". The Therapist also practices a balanced approach to work. Balance involves monitoring the number of cUents one sees and the breaks between clients. Balance also involves being careful not to become grandiose in minking that cUents need you. To this end hoUdays, sick days and other breaks are an important part of working. FinaUy the Therapist needs to live a rich life apart from work including a variety of relationships, sports and leisure activities and interests. This activity is also a part of being protected as a Therapist. "You need a lot of reserves in doing this type of work.  150  You need to have experienced goodness in your own life. You need to have joy". The Co-researcher also advocates laughter as spiritually nourishing.  The Common Experience of Integrating the Spiritual Self The helping professional who integrates the spiritual self has a lot of personal awareness of the spiritual dimension in hved experience. The spiritual self is recognized as an inherent aspect of being yet it is bigger than present reality. The integration of the spiritual self in working emerges from personal clarity regarding how this might be done. It also emerges from hved experiences. The practicalities of integration of the spiritual self are personally developed by the helping professional. Further, this integration is continually reinforced in one's work through repeatedly witnessing the spiritual dimension in work with patients and chents. The Therapist must address personal issues in order to effectively incorporate the spiritual self in practice. Working without the integration of the spiritual self however would render work without value to the professionals. There is a need for the professional to attend to living a rich life and to practice centering techniques for the enrichment of one's spiritual self. The integration of the spiritual self in work is also personally enriching. The effective incorporation of the spiritual self in practice requires personal, professional and spiritual maturity. Suffering is seen as a fact of human experience and it has to do with being somehow disconnected. Looking into the face of one's death holds potential for great change. Addressing one's suffering can lead to profound learning or peace. People have a tendency to avoid suffering. In facing suffering one may encounter their spiritual lives and begin a process of change. Connection to the spiritual domain is of value and it is related to personal health. Change hinges on a spiritual awakening or awareness. Therapy then is a process of becoming attuned to spiritual experience and change.  151  The incorporation of the spiritual self in practice is a mutual experience of the helping professional and the patient or client. A practice of openness in availability or presence to the Patient's or Client's needs is central to the integration of the spiritual self in practice. The relationship between the professional and the patient or chent is essential for purposes of change. Other skills of integrating the spiritual self include active listening skills including the use of the patient's or client's language and their spiritual framework. A professional team is used in the integration of the spiritual self in work though its activities may vary. The incorporation of the spiritual self in practice has to do with the needs of the patients or chents. Because of the lived extremities of the patient and chent population, at times the work seems overwhelming. Regarding the limitations of integrating the spiritual self, some helping professionals may be unable to incorporate the spiritual self in practice. Further, professional models of helping are limited as a result of their failure to address the spiritual self. Professional training fails to consider the spiritual self. This omission has consequences in the work of the helping professionals who integrate the spiritual self in their work. Training in the integration of the spiritual self may be problematic because it is experiential, however it can be done through modeling the skills and through direct instruction.  152  CHAPTER 5 DISCUSSION Introduction The purpose of this chapter is to discuss the results of this study, highlighting findings which are particularly noteworthy, and integrating the findings with the literature reviewed in chapter two. Implications for practice and future research directions will also be discussed. Because the incorporation of the spiritual self in working is a highly personal wisdom this discussion of thefindingsof the study has to be considered in thefightof the hmitations of expression in writing and in an analytical research format. Following is an outline of the majorfindingsof the study. 1. The personal significance of the spiritual self. 2. Two constructions of the spiritual self. 3. Two distinct conceptions of mcorporating the spiritual self in practice. 4. A concept of the process of change. 5. Skills a. The Professional's self is the primary instrument b. Other Skills c. The practice of protection as a therapist 6. The need for professional maturity 7. The client population 8. Professional Limitations 9. Training Major Findings of the Study 1. The Personal Significance of the Spiritual Self The present study supports the findings of Shafranske and Gorsuch (1984) and Shafranske and Malony (1990) who have found that Psychologists who incorporate 153  spirituality in their work alsofindit important in their personal hves. Both of the Coresearchers demonstrated a profound awareness of the influence of the spiritual self in lived experience. A limited way of expressing this is by indicating the vital concern both have for their patient's or clients change despite the extremities which their patient's or chents are living with. Further, both base their incorporation of the spiritual self in their work on a behef system that has arisen out of a great deal of experience of the spiritual self in their work. Tfieoretical constructions of experience play a secondary role in their approach to working. For both of the Co-researchers, the incorporation of the spiritual self in practice is tied to their lived experience. Both have personal experiences of spirituality which reach back into childhood. It can be observed that their constructions of the spiritual self stem from their personal experiences. A has been involved in a Christian way of life since childhood which is reflected to some extent in a theme of journey. B has witnessed or had spiritual experiences since childhood and this is reflected in the theme of transformation. Cohen's (1986) finding that his Co-researchers tend to address the spiritual issues which they themselves have addressed in therapy seems to parallel this observation of the relationship between the Co-researcher's themes and their hved experiences. Perhaps this is an illustration also of B's comment that the counselor takes the chent as far as they themselves have gone. Their incorporation of the spiritual self in helping is connected to the way in which the suffering and change of their patients or clients has affected their convictions regarding the potential of the spiritual self. The Co-researchers also express similarly to Grimm's (1994) comments, that the incorporation of the spiritual self in their work is essential and that its inclusion is desirable in their work. The high degree of personal integration of the spiritual self that the Co-researchers have achieved in incorporating the spiritual self is in contrast to Cohen's (1986) work. Cohenfindsthat Co-researchers have to reject either their rehgious behefs or the principles of psychoanalysis, or they have to engage a compartmentalization of codes in order to keep  154  the two areas distinct in their experience. In the present study, the Co-researchers have evolved an operational construction of the spiritual self in practice and simultaneously indicate the importance of mastery in professional skills and knowledge. There are two possible explanations for the differences. In the first place, Cohen examines his Coresearcher's rehgious rather than spiritual hves. Secondly, Cohen analyses his interviews from the position of psychoanalysis rather than the atheoretical approach used in the present study. The effects of these differences is uncertain. 2. Two Constructions Of The Spiritual Self Both Co-researchers agree with the large body of literature which maintains that the spiritual self is an inherent aspect of being (Aldridge, 1993; Benner, 1988; Grimm, 1994; Jung, 1933; Mack, 1994; Pedersen, 1995, Peterson, 1987; Tjeltveit, 1989; Westwood, 1995). They also express that the spiritual self has to do with relationships as was found in the discussion of theoretical constructs in chapter two (Benner, 1988; Frankl, 1988; Helminiak, 1988; Jung, 1933; Kierkegaard, 1954; Yalom, 1982). Their constructs of the spiritual self however form distinct illustrations of the spiritual self in professional practice. A finding of diversity is not uncharacteristic of the spiritual self (Chandler, Holden and Kolander, 1992). The interaction of these two themes can create an interesting dialogue concerning the nature of the spiritual self in Helping Professions. In combination, the themes foster a sense of paradox and complexity as suggested by Walter (1994). The construct of the spiritual-psychological journey is unified by a model of connectedness to self, other and a higher power. The construct of transformation by contrast, hinges on an awareness of a spiritual reality which is immanent and has the potential to transform life experience. Further contrasts between the two constructs include; time versus the moment, meaning and purpose versus 'isness', transcendence versus immanence, healing versus transformation. It is worthwhile noting that both Coresearchers use the terms of the other's models, yet eachfindsmore richness of expression in their particular framework.  155  Juxtaposing themes has been considered in Kierkegaard's description of humans as spiritual beings: "Man is a synthesis of the infinite and the finite, of the temporal and the eternal, of freedom and necessity, in short it is a synthesis. A synthesis is a relation between two factors" (Kierkegaard, 1954, p. 146). What seems likely here is that the two themes represent different distinctions of the spiritual self. One might speculate that the two views represent different degrees of focus; A's taking a broad perspective and B's taking a point perspective. In any case the contrast of the two constructs serves as a rich depiction of spiritual experience. It is not necessarily the case that these juxtapositions represent opposites or negatives of each other. The discussion in chapter two of the contrasts among the various theorists who have incorporated the spiritual self in their work (Benner, 1988; Frankl, 1984; Helminiak, 1988; Kierkegaard, 1954; Mack, 1994; Yalom, 1982) is worth reviewing in the light of the findings of this study. The contrasts of searching versus immanence, and a generalized view versus deeply intra-personal experiencing are reflected in the two constructions of the Co-researchers. A's can be framed within the former descriptors and B's in the latter. Interestingly Fromm's challenge of relativism in favor of truth-seeking (as cited in Helminiak, 1988), and the issue of psycho-spiritual integration (Benner, 1988) does not pose a challenge to the Co-researchers. Nor does the line of division between the personal and the spiritual (Benner, 1988; Chandler, Holden and Kolander, 1992) become an issue for the Co-researchers. The Co-researchers both express confidence in the patient's or client's lead through their healing process and in this way questions of truth and human functioning become secondary. Apparently their premise of action is healing or change and acceptance before the resolution of philosophical questions. In other words, their confidence in spiritual reality is the motivation for action. The effect is not the erosion of uniqueness as Fromm ( as cited in Helminiak, 1988) suggests it might be, rather, the uniqueness of their patients or cUents is upheld as integral to their process.  156  3. Two Distinct Conceptions Of Incorporating The Spiritual Self In Practice The theme of the journey sees the interaction of the professional and the patient within the broader context of hved experience. It is contextualfy based within a culture, within a profession, within a person. It considers past, present and future. It looks towards a transcendence of present experiencing to a place of healing. It focuses on finding value and meaning. The journey in the therapeutic sense is about moving from being disconnected to a place of connectedness to self, other and some higher power. The theme of the journey is comparable to Frankl's (1988) work in several ways. First of ah Frankl similarly focuses on maintaining a perspective of the whole of personhood, not fragmenting experience into component parts. Like Frankl's logotherapy, the journey theme is growth oriented. Finally, Frankl discusses that self transcendence is a human trait which works in the direction of seeking meaning. This also fits with the journey theme. In contrast to the theme of journey is the theme of transformation. This approach operates in the awareness of a particular though undetermined moment in time when something bigger happens for the client. Transformation may or may not happen in the therapy session. When it happens during a therapy session transformation is a deeply personal experience in response to an immanent spirituahty. It is interesting to note that the description of transformation has the same elements of self (the chent), other (a person or thing) and something bigger (a spiritual reality) that A describes. For B a state of health has to do simply with 'being' or with 'isness'. The experience of transformation is inadequately described as healing, what it actually represents is a different kind of relatedness to one's world. In discussing a finite aspect of human experience the theme of transformation is somewhat similar to Jung's work (Mack, 1994). Similarly to Jung's work, the transformation theme is characterized by homeostasis. Further, Jung's construct of individuation whereby the integrated personality is a spiritual manifestation known as the genuine self is analogous to B's discussion of being or isness.  157  Approaching work using these spiritual premises is not unknown (Aldridge, 1993; Everts and Agee, 1993; Grimm, 1994; Jung, 1933; Pedersen, 1995) and may broaden one's understanding of human mnctioning. Pedersen (1995) discusses that a spiritual perspective of healing is the basis of healing arts in other cultures. He also suggests that it is possible that our rational Westernized approach to helping by its neglect of the spiritual perspective has neglected meaningful avenues of healing. 4. A Concept Of The Process Of Change The Co-researchers present a view of change which starts from the place of suffering. Suffering is the experience of being somehow cut-off in relationships. From the place of suffering the Co-researchers discuss that there is increased openness to spiritual experience. It is in coming into relationship with spiritual reality that profound change can occur. Change is indicated in a change in relatedness. Aldridge's (1993) and Pedersen's (1995) discussions of working through suffering to come to a new understanding represents the awareness of the potential in suffering which is expressed by both Co-researchers. The Co-researchers discuss that at one level suffering is an inevitability of human experience. They also find however that there is some point in suffering which has the potential to open a person to spirituahty. Aldridge talks about needing to work through suffering to a place that is beyond suffering. He uses both terms; transcendence and transformation to discuss this experience. Pedersen discusses the movement through suffering to attain inner freedom and the experience of one's divinity. For Pedersen the capacity to find meaning in suffering is directly related to one's religious or spiritual hfe. The experience of change has to do with acceptance, it is characterized by a different manner of relatedness. For A change is represented in the experience of healing relationships to self, other and one's god consciousness. For B change is represented in the experience of a new relatedness to the world. Both Co-researchers express that the experience of connectedness to something bigger or to a god consciousness is necessary  158  for change to transpire. Their concept of change goes deeper than simply new patterns of interaction or new insights yet their attention is not on the individual's spiritual growth, but on their personal development as discussed by Grimm (1994). The Co-researcher's observations regarding change parallel Jung's (1933) and Aldridge's (1993) discussion of the spiritual nature of health. The issues of choice and journey were discussed by both of the Co-researchers. They do not form a significant portion of the change process for both Co-researchers rather each is favored by one of the Co-researchers and mentioned by the other. Both Co-researchers discuss that choice is an element of change. A does not expand on the nature of the choice but B discusses that one may either choose or be chosen by life. Fromm ( as cited in Helminiak 1988) discusses choice as it relates to spiritual commodities of value, morality and so on. The extent to which he has captured A's discussion of choice is arguable but his work falls short of capturing B's immanent sense of spiritual reality. The Co-researchers indicate that a journey plays a part in the change process. For A this journey is ongoing and multi-dimensional. For B on the other hand the journey is specifically in relationship to a transformational experience. Benner's (1988) discussion of spiritual quests as a common orientation of human nature similarly describes people journeying to desired ends. 5. Skills 1. The Professional's self is the primary instrument The Co-researchers find that a spiritual connection is important for change to transpire. A's description is holistic in this regard including relationship to self, other and a higher power. B focuses on the necessity for the client to become connected at a spiritual level. The Co-researchers indicate that the patient's or chent's connection with someone or something is the beginning of change and it can lead to this essential spiritual connection. In this way the spiritual relationship necessary for change could be fostered through the  159  patient's or client's relationship with the professional. That the therapeutic relationship is key to change has been considered in counseling (Corsini and Wedding, 1989). The spiritual dimension of the helping relationship however has not been discussed in the literature and it has a significant effect on the professional understanding of the helping relationship. In this regard B is careful to point out that this potential does not lie within the grasp of the helping professional's influence but it may or may not be emergent in the process of counseling. A concurs with this perspective in advocating respect for the patient's initiative on their journey. The Co-researchers incorporation of the spiritual self in practice is centered on; for A the practice of availability to the Patient, and for B the practice of presence to the client. Avariability is related to the ethical principle of fidelity and it has to do with identifying and addressing the patient's needs beyond the prescribed relationship of the Doctor and patient. Presence for B is an unquestioning commitment to follow the client in whatever direction they might need to go. What these skills indicate is a profound ability of the professional to rely on their skill in connecting with the patient's or client's experience. In this way the work is a personal journey of the professional's as suggested by Anderson (1994), rather than an exercise in neutraUty. The Co-researchers express that practicing availability or presence is a personal and professional investment in the helping relationship, this perspective challenges the concept of sphtting between the personal and professional suggested by Cohen (1986), Grimm (1994), and Strupp (1980). Cohen (1986) in particular finds that "the first major conclusion of [his] study is that the anticipated higher order personal integration of the seemingly irreconcilable perspectives of psychoanalysis and religion seldom, if ever, occurred on the part of our sample" (p. 222). That a question of integration does not arise for the Co-researcher's in this study may have to do with the atheoretical framework of this study, it may also indicate that integration of theoretical and spiritual perspectives is possible.  160  Both speak of being affected by their patient's or client's experience and both underline the necessity to address personal issues, both those related to work and those not related to working. This personal emphasis is reflective of Sims' (1994) view that the spiritual self of the counselor needs to be employed in incorporating the spiritual experience of the patient. The Co-researchers are in agreement that at times their work seems overwhelming. They also find that their work is personally gratifying and both find that without incorporating the spiritual self their work would become pointless and be reduced to simply a job. Mack (1994) and Tjeltveit (1989) both discuss that bringing a personal element to working is an advantage in practice because it causes the professional to address counter-transference issues and can increase consistency for counselors in their theory, research and practice. The result is a helping relationship characterized at least in part by a mutuality of helping. For both Co-researchers the continuing incorporation of the spiritual self in working is based on repeatedly witnessing their respective constructions of the spiritual self in their patient's or client's experience. A consistently finds that healing occurs in resolving relationships to self, other and a higher power. B consistently finds that transformation happens when people become connected to something bigger. Against the background of their personal experiences, their professional maturity, their desire for and belief in their patient's or client's healing and their repeated encounters with the spiritual self in their patient's or clients change experiences, the incorporation of the spiritual self in their work is unavoidable. 2. Other Skills The Co-researchers place central emphasis on practicing availability or presence to their patients or cUents. This approach of open responsiveness demonstrates their premise of trusting the wisdom of the patient or cUent in choosing their way through their process of suffering. The attitude of respect in working with patients or clients reflects Grimm's (1994) discussion of working in the acknowledgment that spiritual reaUties exist and affect  161  behavior. Their work is in stark contrast to the pathologizing view of spiritual experiences suggested in several models of incorporating the spiritual self (Griffith, 1986; Spilka, 1986; Worthington, 1989). The Co-researcher's supportive approach is reflected instead in Pederson's (1995) discussion of looking to the "endogenous or 'inside the person' sources of spiritual empowerment" (p. 2). Their singular attention to their patients' or clients' process is perhaps why neither of the Co-researchers expressed concerns with the countertransference of spiritual issues which Cohen (1986)findsin his study. The result of focusing on practicing presence or availability is that the Co-researchers describe their professional roles more in terms of service to their patients' or clients' needs than professional neutrality and diagnosis. In this way they challenge the social paradigms of professional power which Harrison (1988) and Sims (1994) discuss. Basic listening skills including attention to language and non-verbal behavior underhe the practice of incorporating the spiritual self. Both also use the spiritualframeof the patient or chent. The Co-researchers emphasize also that the professional needs to be flexible in accommodating the patient or chent. Flexibihty could take many forms. B spoke of the use of symbol and ritual with chents. Peterson (1987) similarly endorses the use of symbol and ritual and goes further than B using music, meditation and visuahzation. Being non-directive and working within the patient's or client's framework in incorporating the spiritual self in practice is generally supported in the literature (Peterson, 1987; Sims, 1994; Stewart and Gale, 1994). A however makes a point of raising the issue of the spiritual self. This somewhat directive approach is in response to the social denial which fosters an unawareness on the part of the patient and may preclude spiritual-psychological treatment in a medical setting. A directive approach is also supported in the literature (Clinebell, 1972; Peterson, 1987; Sims, 1994; Westwood, 1995; Worthington, 1989). That the exploration of the spiritual self raises peculiar vulnerabilities of the patient or chent warrants particular attention. A finds that social denial negates the spiritual self and B finds that chents have a sense of being perceived as crazy when they talk about their  162  spiritual experience. These observations support the perspective of spiritual cynicism in American culture discussed by Snow and Willard (1989) as well as the view that the spiritual self is (or is not) culturally affirmed as discussed by Pederson (1995) and Everts and Agee (1993). To address this problem, several authors advocate cross-cultural training with respect to spiritual issues (Grimm, 1994; Pate and Bondi, 1992; Pedersen, 1995). Both Co-researchers referred to their professional teams as places where team support, skill development and personal issues could be addressed. The teams of the Coresearchers serve distinct purposes A's team being developed for specialized work and B's team forming the more familiar professional consultation. It can be seen however that the personal and professional demands on these teams exceed the standard of consultation ordinarily observed. Finally, Grimm's (1994) and Peterson's (1987) discussions of unique techniques that are used as a result of incorporating the spiritual self in practice were not found. Grimm and Peterson suggest that the client's spiritual or religious practices such as prayer, meditation, music, or attendance at a place of worship can be used. The Co-researchers did not discuss these techniques. Their advocacy for using the patient's or chent's rehgious or spiritual frame however suggests that perhaps these techniques may be incorporated as a result of the practice of availability or presence. 3. The practice of protection as a Therapist B's concept of the Therapist's protection is an important discussion in considering how the spiritual self is incorporated in helping. It represents a majorfindingof the project and as a result is discussed here at some length. The Therapist's need to practice protection is directly related to how present the Therapist must be to the client's process in a practice which incorporates the spiritual self. B discussed that the elements of protection involve rituals in preparation for chents, and following their departure. The opening ritual is used to center the Therapist and position them "one step back" in preparation for opening up to the client's process, and to welcome  163  the client into the session. The closing ritual following the session is used to release the client and the therapy hour. According to B it is from the position of "one step back" that the Therapist can hear the client's journey without becoming caught in counter-transference. Strupp's (1980) discussion of the Therapist's practice of separating personal and professional values may be related to B's concept of one step back. Strupp's discussion however seems to indicate a kind of splitting while B talks about being fully present emotionally and cognitively with the client, yet being protected in one's soul. Two other aspects of being protected include practicing a balanced approach to working and living a rich life. Balance in work entails not becoming overbooked, pacing one's working day, taking sick days, breaks and holidays. This balanced approach is stabilizing and counters the tendency to get caught in a self-aggrandizing perspective that clients need you. Arichlife is characterized by participation in enriching activities such as the Arts, sports, laughter and relationships. Knowing joy and goodness in life is also enriching. For B protection also arises out of developing a relationship with one's spiritual self. A addresses this issue in discussing personal practices of connectedness to self, other and God. A spends time alone in prayer, reflection and reading. A takes care of relationships with friends and family and attends church. A's activities address B's concept of developing a relationship with one's spiritual self, whether A experiences this as protective is unknown. B's model of protection is comparable in some ways to Anderson's (1994) discussion of the therapist's relinquishment. Anderson employs ritual at the opening of the day and will use visualization during the therapeutic hour to open himself to the client's experiencing. Anderson uses relaxation, visualization and focusing in an effort of relinquishing control of the therapeutic process to God. Like B, Anderson consciously sets aside the ongoing business of daily living. Like B, Anderson attends to releasing the  164  therapeutic hour after it is over. Anderson does not however discuss the protection of the therapist in using his approach. 6. The Need For Professional Maturity The Co-researchers indicated that the spiritual self is effectively incorporated at a point of professional maturity. Maturity is reflected in mastery of the skills of the profession, the process of time, and experience. This finding is supported in the literature (Grimm, 1994; Mack, 1994; Strupp, 1980; Tjeltveit 1989; Weiskopf-Joelson, 1980), with particular reference to the importance of careful reflection on one's model. One significant element of the need for professional maturity is the fact that the professionals have evolved their understanding of integrating the spiritual self through their own and their patients' and clients' experiences. Grimm (1994) discusses the need for integration of the Therapist's spiritual and religious values with their epistemic values. This is reflected in this study in that both of the Co-researchers have made adaptations in their theory and practice which are in keeping with their recognition of the need for the spiritual self in their work. Both Co-researchers have achieved a high degree of credibility in their respective professions and both have a very articulate understanding of what incorporation of the spiritual self in working is about. 7. The Client Population Another important finding of this study is that the client population is central to the incorporation of the spiritual self in helping. Both Co-researchers noted that their patients or cUents are in particular Ufe circumstances whereby they are somehow opened to interaction with a spiritual dimension of Uving. Their openness has to do with the fact that the patients or cUents are currently confronted with suffering and death. A vulnerabiUty to the spiritual self is not reflected, in the literature most notably not in Chandler et al.'s (1992) definition of spirituaUty used in this project. The Uterature instead tends to point to either spontaneous spiritual experiences which affect therapy (Anderson, 1994; Holmes, 1994) or  165  to the incorporation of spirituaUty in therapy with religious patients or clients (Griffith, 1986; Stewart & Gale, 1994). Interestingly this study has not supported the assumption in the literature (Anderson, 1994; Chandler et al., 1992; Holmes, 1994; Westwood, 1995) that the spiritual self is part of an ordinary therapeutic process. This again may be due to the patient and client populations who are dealing with extremities of hved experience. The Co-researchers both state that ordinary treatment is different. On the other hand, the technical skills of incorporating the spiritual self are remarkably commonplace. This divergence of discussion warrants further exploration. 8. Professional Limitations Both Co-researchers discussed the limitations of their professional models to address the spiritual dimension of treatment with their patients or chents. In part they are in agreement with the literature which discusses the effects of the dominant empirical and postivist paradigms (Bergin, 1988; Sims, 1994; Tjeltveit, 1989). Both have also experienced a silence around the topic of the spiritual self in their professional circles and both feel that this needs to change. The Co-researchers also discuss that current research neither identifies nor addresses their experiences with their Patient's or Client's needs. Similarly, Benner (1988) and Tjeltveit (1989) talk about the failure of current research to reflect the Therapist's experience of the complexity of the therapeutic encounter. Finally both indicate that some professionals may be somehow unable to incorporate the spiritual self in their work. The failure to incorporate the spiritual self may be related to Shafranske and Malony's (1990)findingof a relationship between the therapist's confidence in their belief system and their use of a spiritual perspective in their work. It may also be a result of professional bias regarding the incorporation of the spiritual self as suggested in Jensen and Bergin's (1988) survey findings.  166  9. Training That training neglects the incorporation of the spiritual self in working is another finding of the study. This neglect in training facilities is consistent with Kelly's (1994) study which showed that North American Counselor Training institutions neglect to address spiritual issues despite the finding that Department Heads feel it is an important issue to address. The Co-researchers both found their training was overly focused on academic knowledge and failed to consider either the spiritual self or related to this, the important issues of personal experience. Both Co-researchers suggest that it might be difficult to incorporate the spiritual self in training, yet both suggest it can be done using modeling and teaching. Both Co-researchers take advantage of teaching opportunities to convey the incorporation of the spiritual self in helping. Pate and Bondi (1992) find that the spiritual self is sufficiently important in counseling practice that its neglect has a negative influence on practice as a result of counselor bias.  Implications of the Study The findings of this project have a number of implications in considering how the spiritual self is integrated in helping professions. To begin with models of helping need to be re-examined to address the spiritual dimension of working with patients and cUents. These models need to operate on a fundamental assumption that spirituaUty is an inherent human characteristic. Erroneous concepts of neutrality need to be replaced with a challenge to engage the task of helping from a deeper place of working from a place of trusting the patient's or client's process. The process of therapy can be reconsidered as a spiritual-psychological journey during which experiences of transformation can occur. The patient's or cUent's experience of connection to a person or thing can precipitate a connection to the spiritual with an associated potential of change. The helping professional also needs to recognize that therapy occurs within a context of social, professional, personal and spiritual dimensions.  167  Helping professionals need to re-examine the problem of suffering. In this study we have found that suffering, the spiritual self and change can be linked. Change that emerges from suffering is profound in its nature characterized by new forms of relatedness to the world, to one's self and to one's god consciousness, rather than simply new patterns of interaction, or new insights. The helping professional is the key element of incorporating the spiritual self in helping, as a result, personal and professional maturity are required. To this end it is necessary that the helping professional; work through whatever personal issues they encounter, thoroughly work through their practice models, and cultivate their spiritual selves. It must be understood that the integration of the spiritual self arises from the personal wisdom one develops. Confidence in one's behef system is necessary for an active integration of the spiritual self. Further, the helping professional needs to have a fundamental behef in their patients' or chents' ability to heal despite the extremity of their circumstances. The common basic listening skills including flexibility, attending to non-verbal behavior, using the Patient's or Client's spiritualframeand their language are key techniques of integrating the spiritual self. Woven through these skills however is the attentive practice of availability or presence. Availability or presence are the means by which the unique process of the Patient or Chent can be supported. The openness required of the professional in practicing availability or presence fosters a kind of mutuality of helping between the Helping Professional and the Patient or Client. The Co-researchers both indicate that the work is more characterized by service than authority in relationship to the Patient or Chent. This is a radical undressing of the dimension of power commonly encountered in professional circles. In opening themselves so much to the patients or chents experience, the practice of protection by the Therapist is warranted. To this end balance in one's approach to working  168  and attention to living arichlife are necessary activities. Helping professionals need to be supported in pacing their working day and in taking breaks, holidays and sick days. This study has also found that the incorporation of the spiritual self is appropriate with patients or clients at extremities of lived experience. Using this approach with more commonplace issues of patients or cUents is not supported. The two models of incorporating the spiritual self in helping provide a rich contrast of understanding regarding how the spiritual self can be incorporated in helping. This contrast suggests that there are different ways of understanding the spiritual self as it is integrated in work. Reasons for differences may include different professions, different Ufe experiences or the particular needs of one's patients or cUents. There are several impUcations drawn from the theme of the journey. Healing occurs over a process of time and it is multi-dimensional including not only the individual but their culture. The medical paradigm is in need of suitable models for addressing the spiritual needs of patients. Medical professionals are for the most part lacking in the skiUs needed to facilitate patients' process of healing. Healing itself needs to be understood in more than simply physical terms, it also includes the spiritual-psychological healing of relationships to self, other and one's god consciousness. The theme of transformation suggests the need for professionals to become open to the potential of a spiritual dynamic in the process of therapy. Rather than focusing on skiUs and one's abiUty to steer a therapy session, the professional needs to be free to let go of control and invest themselves instead in the cUent's process. Becoming open and embracing one's unknowing need to become central in the process of therapy. There is a need for training programs to address the spiritual self. This needs to happen in the form of addressing the personal issues of counselors and considering how the spiritual self can be appropriately integrated. Cross cultural training in this area is an important area of training. Further, B noted that there is a need to address student issues of despair. A was concerned that medical schools need to include training in a respectful  169  counseling approach to patient interviews. Both Co-researchers advocate teaching and modeling as appropriate means of training regarding the integration of the spiritual self in working. There is a need for the spiritual self to move into professional discussion. Not only did both Co-researchers address this, their different models of incorporating the spiritual self demonstrate such a richness of practice that broadening the discussion could prove to be very rewarding. Further, the Co-researchers have found that professionals are wanting to consider this area in ways that are professionally tenable. The use of existential phenomenological research with a professional population on this meaningful topic is questionable. Significant issues of confidentiality arise given that this is such a deeply personal topic. Further, both Co-researchers have expressed frustration with seeing their spoken word in text as both felt they would express themselves better if they had written their responses themselves. B suggested that in future time might be contracted for the Co-researcher to participate in writing the quoted material. A further implication of this study is the tremendous need for more research into the spiritual self.  Future Research There are a number of questions that arise specifically from the findings of this study: 1) . This project suggests that there is a point of vulnerability to spirituality. A study to verify this finding may be worthwhile. 2) . Research questions which consider whether the spiritual self is integrated with patients or chents who are in less extreme circumstances in their lives is indicated from this project. 3) .Further exploration of the concept of the therapist's protection is also warranted research.  170  4) .A needed area of research is the development offramingprograms which incorporate the spiritual self. Both Co-researchers commented on the failure of training programs to address personal issues and the inclusion of the spiritual self. 5) .Further studies need to be done using the construct of the spiritual self rather than that of religion. This is suggested for example in the contrast of findings regarding the issue of personal and professional 'splitting' between the present study and Cohen's (1986) study. 6) .The present study could simply be expanded using appropriate adjustments to existential-phenomenological methodology. With a population of two Co-researchers this has proven to be a very rich study which may only be enhanced by the inclusion of more Co-researchers. Alternately, an exploration of conceptualizations of integrating the spiritual self in practice to explore the point of redundancy would be a valuable further step. 7) . Research into the use of a directive and non-directive approaches in specific professional venues would also be valuable. In this study it was found that a non-directive approach was generally used, but that a directive approach was needed in a medical setting which does not typically consider spiritual-psychological issues. 8) .Further research into helping professional's experiences of therapy and of patient's and client's needs is also required. This is in response to the finding of both Coresearchers that current research does not address their experiences with their patients or cUents. 9) .Comparable studies which address some of the Umitations of the present study may also be worthwhile. A more narrow focus on a particular helping profession for example would be appropriate.  Summary The integration of the spiritual self in helping professions is about the investment of the helping professional in their personal, professional and spiritual Uves. The therapy itself  171  looks a lot like the practice of therapy offered in counselor training programs. The difference however is that the professional recognizes the influence of the spiritual self in their own lives, in the lives of their patients or clients and in the process of their work together. The effect of this difference is significant given the empirical paradigm that counseling practice has arisen from. The context of understanding one's work is much broader ranging from awareness of the unhealth of our society; to knowledge of the potential of the spiritual self to address this tremendous need, to an understanding of the potential for transformational change from a place of suffering. Personal and professional maturity are necessary preUminaries to a practice which demands a tremendous degree of openness in availability and presence to the experience of another person who is at an extremity of lived experience. The professional is required to put down the protective vestiges of professionalism and engage from a deeply human level. The two themes of incorporating the spiritual self in practice are rich in their descriptions of how the spiritual self brings healing or transformation through a therapeutic process. Each of these approaches suggest a different theme of integrating the spiritual self in helping which is expressed in their understanding of change. Change can be seen as a spiritual-psychological journey towards an experience of acceptance of one's inevitable death. Change can also be seen as a transformational experience where one is met at a spiritual level and in consequence achieves a new form of relatedness to the world. These themes have emerged from the experiences of the Co-researchers and they point to the need to broaden this discussion in professional circles through research and discussion. Professionals are looking for ways to understand this meaningful aspect of their work with patients and cUents. Current models of practice are insufficient to capture the spiritual self. Training programs also neglect to address the spiritual. AU of these areas suggest research which is needed as professionals grapple with the appropriate integration of the spiritual self in helping professions.  172  The current project indicates the tremendous personal chaUenge for professionals who integrate the spiritual self in their work. It also suggests how rich and how significant the integration of the spiritual self in practice can be.  173  Bibliography Aldridge, D. (1993). Is there evidence for spiritual healing? ADVANCES: The Journal of Mind-Bodv Health. 9(4). 4-21. Anderson, D. A. (1994). Transcendence and relinquishment in couple therapy. Journal of Systemic Therapies, 13(3). 36-41. Benner, D. (1988). Psychotherapy and the spiritual quest. Grand Rapids, MI: Baker Book House. Berenson, D. (1990). A systemic view of spirituality: God and twelve step programs as resources in family therapy. Journal of Strategic and Systematic Therapies, 9, 5970. Bergin, A. E. (1980). 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How has your incorporation of the spiritual self in your work affected your understanding of the process of helping, how it has interacted with your theoretical training and background, how it has affected your view of your chent and of yourself as a professional, the related techniques you've used and so on. 1.  Tell me the story of how you have incorporated the Spiritual Self in your work as if it is a story with a beginning, a middle and an ending.  2. Defining  -what do you understand as the Spiritual Self?  3. Process  -how is it connected to you personally? -how do you perceive it in your clients? -Please describe effective helping including how the Spiritual Self contributes to it?  4. Theory theoretical  -how have you integrated your concept of the Spiritual Self with your approach to helping? -Please talk about the relationship of the Spiritual self to suffering and healing  5. Technique -please talk about your general guiding principles of discussing the Spiritual Self with your chents. -what techniques do you use that are specifically related to your concept of the Spiritual Self? -How do you nurture your own Spiritual Self in relation to your work? 6. Training 7. be  -What if any professional training is needed in this area?  -What do you think about your approach in comparison to other approaches? -If you didn't have a sense of the spiritual self, what would doing this work like?  Closing: Thankyou for your contribution to this project. As you know I will contact you after I have done some analysis for your validation in a second interview. In the meantime, if you find upon reflection that there is more material you'd like to add to the discussion we've had today, please record your thoughts on paper for me to include in the analysis. I would be happy to pick these up anytime in the next couple of weeks.  182  APPENDIX D THE INVITATION It doesn't interest me what you do for a living. I want to know what you ache for, and if you dare to dream of meeting your heart's longing. It doesn't interest me how old you are, I want to know if you will risk looking like a fool for love, for your dreams, for the adventure of being alive. It doesn't interest me what planets are squaring your moon.... I want to know if you have touched the center of your own sorrow, if you have been opened by life's betrayals or have become shrivelled and closed from fear of further pain. I want you to know if you can sit with pain, mine or your own, without moving to hide it, or fade it, or fix it. I want to know if you can be with JOY, mine or your own; if you can dance with wildness and let the ecstasy fill you to the tips of your fingers and toes without cautioning us to be careful, be realistic, or to remember the limitations of being a human. It doesn't interest me if the story you are telling me is true. I want to know if you can disappoint another to be true to yourself; if you can bear the accusation of betrayal and not betray your own soul. I want to know if you can be faithful and therefore be tmstworthy. I want to know if you can see beauty even when it is not pretty every day, and if you can source your life from ITS presence. I want to know if you can live with failure, yours and mine, and still stand on the edge of a lake and shout to the silver of the full moon, "YES!" It doesn't interest me to know where you live or how much money you have. I want to know if you can get up after the night of grief and despair, weary and bruised to the bone, and do what needs to be done for the children. It doesn't interest me who you know or how you came to be here. I want to know if you will stand in the center of the fire with me and not shrink back. It doesn't interest me where or what or with whom you have studied. I want to know what sustains you from the inside when all else falls away. I want to know if you can be alone with yourself and if you truly like the company you keep in the empty moments. by Oriah, Mountain Dreamer, Indian Elder  183  


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