16 APA PRACTICE ORGANIZATION Putting Your Business Plan to Work Creating or refining a plan is a necessary step in charting a path to successful practice. I n today’s competitive and evolving health care marketplace, psychologists must clearly address the business side of practice. In order to survive and thrive, independent psychology practices and behavioral health organizations of all sizes should have a business plan. Your roadmap for the future, a business plan is equally important for solo and small group practices as is it for larger organizations. Just as a good treatment plan keeps the patient on track to reach goals and maintain health, a business plan will help psychologists set business goals and maintain a successful practice. Going through the exercise of developing a business plan – including stating your mission, describing your marketing plan and anticipating finances for the next few years – helps you focus on important aspects of growth. If you are considering participating in or implementing an alternative practice model such as an independent practice association (IPA) or medical services organization (MSO), a more comprehensive business plan must be fully developed, especially if you need outside funding. Many resources, including those listed in the sidebar on page 13, may help you create your business plan. For example, the Small Business Administration provides templates at no cost which can be found online at www.sba.gov/writing- business-plan. The APA Practice Organization provides further information on the Practice Central website for practitioners on elements to include in your plan. This article will briefly outline steps in developing a business plan for your practice and how to begin putting your plan to good use. Look at the present and envision the future To build a business plan, you need to assess your current practice and articulate goals related to future directions. For example, do you have a specialty practice? Are you primarily a consultant, child psychologist, group psychologist, an expert in a particular treatment area such as dialectical behavioral therapy or hypnotherapy, or perhaps all of the above? What portion of your practice is private pay? Considering such questions helps you identify your starting point. As you begin the business plan exercise, you may find that you wish to modify certain aspects of your practice or head in a different future direction. If you have already formed or are participating in a mental health provider group, the personal and professional characteristics of all group members who would potentially be part of any new venture should be considered. In addition to determining individuals’ professional areas of competence and expertise, you should consider factors relating to the structure and characteristics of the group as a whole. For example: Who are the group leaders and ALT ...

1. 16 APA PRACTICE ORGANIZATION
Putting Your Business Plan to Work
Creating or refining a plan is a necessary step in charting a path
to
successful practice.
I
n today’s
competitive and
evolving health
care marketplace,
psychologists
must clearly
address the
business side
of practice. In
order to survive
and thrive,
independent
psychology
practices and
behavioral health
organizations of all sizes
should have a business plan.
Your roadmap for the future, a
business plan is equally important
for solo and small group practices as is it for
larger organizations.

2. Just as a good treatment plan keeps the patient on track to
reach goals and maintain health, a business plan will help
psychologists set business goals and maintain a successful
practice. Going through the exercise of developing a
business plan – including stating your mission, describing
your marketing plan and anticipating finances for the next
few years – helps you focus on important aspects of growth.
If you are considering participating in or implementing
an alternative practice model such as an independent
practice association (IPA) or medical services organization
(MSO), a more comprehensive business plan must be fully
developed, especially if you need outside funding.
Many resources, including those listed in the sidebar on page
13, may help you create your business plan. For example,
the Small Business Administration provides templates at
no cost which can be found online at www.sba.gov/writing-
business-plan. The APA Practice Organization provides
further information
on the Practice
Central website
for practitioners
on elements to
include in your
plan.
This article
will briefly
outline steps
in developing a
business plan for

3. your practice and
how to begin putting
your plan to good use.
Look at the present and
envision the future
To build a business plan, you need to assess
your current practice and articulate goals related to future
directions.
For example, do you have a specialty practice? Are
you primarily a consultant, child psychologist, group
psychologist, an expert in a particular treatment area such
as dialectical behavioral therapy or hypnotherapy, or
perhaps all of the above? What portion of your practice is
private pay? Considering such questions helps you identify
your starting point. As you begin the business plan exercise,
you may find that you wish to modify certain aspects of
your practice or head in a different future direction.
If you have already formed or are participating in a mental
health provider group, the personal and professional
characteristics of all group members who would potentially
be part of any new venture should be considered. In
addition to determining individuals’ professional areas
of competence and expertise, you should consider factors
relating to the structure and characteristics of the group
as a whole. For example: Who are the group leaders and
ALTERNATIVE PRACTICE MODELS
GOOD PRACTICE Fall 2014 17

4. what is the quality of their leadership? How cohesive is the
group? Who owns the group and what are the contractual
relationships between members of the group?
Assess your readiness for change
Are you satisfied with your practice and your business
model? If the answer is “yes,” the rest of the process will
be fairly simple to complete. If the answer, however, is
“no,” you will need to take a hard look at your practice,
beginning with considering your readiness for change. This
exercise involves assessing personal as well as professional
characteristics. Relevant personal characteristics include
your career stage (early, middle or late), your inclination
toward change and your level of entrepreneurship and risk
tolerance. Relevant professional characteristics include
the services you can provide, your areas of expertise, your
experience working in multidisciplinary teams and/or in
primary care settings, your current professional network
and your technological capabilities.
Evaluate the market
Once you assess your practice and readiness for change, the
next step is to carefully assess marketplace opportunities
in your area. This stage is very important for establishing a
solid business plan.
Many psychologists can assess the market on their own,
using tools such as online research, informal surveys or
focus groups. Another option is to hire an expert to conduct
a market analysis for you, which may be a good option if
you are planning to invest a substantial amount of money
in launching a new venture.

5. Marketplace assessment often includes considering the
following questions:
Consider
factors such as population density, demographic
characteristics (for example, age, diversity and education
levels), local industry and the economic climate.
In considering
options within the third-party payment system,
determine the number of private health insurers, whether
you are able to join their networks and psychologists’
experience in participating with various insurers. Find
out the percentage of Medicare and Medicaid (if the
program in your state allows psychologists to provide
services) recipients in your area, along with applicable
reimbursement rates from these programs. You may also
wish to consider opportunities outside the insurance
system, such as the availability of court evaluations and
other forensic work and teaching opportunities.
Identify other mental health
providers and groups (including master’s level) and
the number of providers who claim to offer the same
specialty areas of practice as you do.
competitors do not? Your business plan can help you
pinpoint unique aspects of your practice to use to your
competitive advantage.
The results from this research will help you decide your
next steps. If you specialize in aging populations but live
in an area where the mean age is considerably younger,
you will likely want to diversify your practice. If you speak
a foreign language, you will want to identify potential

6. clients and other providers who do as well. If you identify
an unmet need, you may decide to develop a new area of
expertise or to add staff members. Conversely, if the market
is saturated with providers in a certain area of practice, you
Psychologists with little to no background or interest
in business will need the assistance of other types
of professionals to make significant changes to their
practices or set up new ventures. For example,
attorneys, accountants and business consultants with
relevant expertise can help psychology practices and
multidisciplinary group practices grow and thrive.
Large group practices and alternative models such
as IPAs and MSOs clearly require the services of an
experienced attorney in setting up legal structures
and providing general legal advice as needed. Solo
practitioners and small group practices may want to
hire an attorney as well, particularly if they decide
to create formal business structures beyond sole
proprietorships – for example, a corporation or
partnership (See the article on page 4).
Accountants can be helpful to all types of practices,
from solo practitioners to large organizations. Larger
groups that participate in payment models other than
fee-for-service – for example, capitated payments and
accountable care organizations) in particular may need
the services of an accountant, financial consultant or
other qualified professional to help them predict the
bottom-line impact of these forms of payment.
GETTING THE PROFESSIONAL
ASSISTANCE YOU NEED

7. may wish to highlight other areas of treatment you
can provide.
Drawing on an example from the field, Dr. Keith Baird
from Illinois is in the process of launching a management
services organization (MSO). Before taking steps to put his
plans in action, however, he researched the local market
conditions by networking with leading health professionals
and researching provider groups and organizations. Dr.
Baird determined that there were no local behavioral health
organizations poised to provide services to the large health
systems and ACOs being formed in his geographic area.
Although he already ran a successful and relatively large
group mental health practice, Baird decided to launch an
MSO. The business goals of this MSO include becoming
the provider network of choice for local ACOs and health
systems, as well as being able to negotiate directly with
health insurers on behalf of the MSO’s providers. These
goals complement the MSO’s broader goals of promoting
integrated, cost-effective, high quality care.
The next step is to plan your income and expenses for
the next several years. This section of your business plan
should include: three-year projections of your income
statement and balance sheet; a cash flow analysis that
documents the movement of money in and out of your
practice, such as reimbursement from health insurance
payers and monthly rent for your office space and the
timing of these transactions; and short- and long-term
capital requirements.
Project how many clients you need to see or other work you
need to undertake in a typical work week to meet expenses.
Based on reimbursement amounts from any third-party
payers, consider whether you also need to see private
pay patients or do some higher paying work that does not

8. involve insurance reimbursement. Likewise, you must
project expenses for the next several years such as staffing,
professional development, overhead and insurance.
Develop an action plan
You may find that you need to access outside capital or
obtain further training to develop and implement your
plans. If you are envisioning a larger venture that involves
a substantial capital investment, you may need to analyze
in some detail the factors that may impact financial
feasibility. For example: Will the planned investments in
infrastructure and/or staff result in substantial efficiencies
and/or economies of scale? Will the structure of the new
venture position your group for success under newer
reimbursement models beyond fee-for-service (for example,
capitated or bundled payments)? What is your bargaining
power in the community?
You may decide that you and/or other professionals in your
group need to develop new skills before launching a new
venture. For example, more than 40 of the mental health
professionals affiliated with Behavioral Care Management
(BCM), the MSO being developed by Dr. Keith Baird, have
obtained post-graduate training and certification in Primary
Care Behavioral Health.
You may also find that your staffing, office procedures,
or health information technology (HIT) capabilities need
to be enhanced in order to pursue your business plans.
For example, electronic health records, secure scheduling
software and performance measurement procedures may
be needed to promote efficiency and to demonstrate
accountability. APA Practice Organization (APAPO) and
APA resources and information that may helpful regarding

9. HIT and accountability include the outcome measures
database “PracticeOUTCOMES” (apapracticecentral.
org/update/2011/08-29/measurement-database.aspx) and
18 APA PRACTICE ORGANIZATION
GOOD PRACTICE Fall 2014 19
HELPFUL RESOURCES
Visit the apapracticecentral.org “Business of
Practice” page (apapracticecentral.org/business/
index.aspx) for information on practice management,
practice marketing and financial management. In
particular, the APAPO article “Your Business Plan:
Steps to Success” (apapracticecentral.org/business/
management/tips/secure/business-plan.aspx)
describes the following basic elements of a business
plan for psychologists: overview (including mission
and vision); environment (including external factors
such as economic trends and demographics as well as
internal factors such staffing and facilities); marketing
and finance. Much of the material in this section of
the Practice Central website is available only to APA
Practice Organization members.
The Small Business Administration provides business
plan templates at no cost, which can be found online
at www.sba.gov/writing-business-plan.
Another resource that may be helpful in developing
your business plan is the detailed “Decision Model
for Practices” developed by Dr. Charles Cooper of
North Carolina. Dr. Cooper’s model is designed for

10. psychologist practices that are considering becoming
more involved in integrated care. See the References
and Resources list on page 13.
Continuing Education (CE) courses may also serve
as good resources for planning and implementing
changes to your practice. For example, APA offers
many useful CE courses (online at www.apa.org/
education/ce/index.aspx), including the following:
“Moving Your Psychology Practice to Primary Care
and Specialty Medical Settings: Competencies,
Collaborations and Contracts;” ”Building Your
Practice Through Interprofessional Collaboration
With Health Care Providers” and “Using Science and
Entrepreneurship to Identify Practice Markets and
Opportunities.” Your state psychological association
or other approved CE providers may also have helpful
resources.
Since most psychologists do not have business
expertise, many practitioners are assisted by other
professionals such as an attorney, an accountant and/
or a business consultant. See sidebar on page 17.
APAPO’s Practice Central webpage on “Technology and
Electronic Health Records” (apapracticecentral.org/
business/technology/index.aspx).
Put your plan to work
Establishing and maintaining close connections within
your community and remaining flexible are keys to
successful implementation of your business plan.
Staying Connected. Psychologists need to maintain and
grow their professional network. Your network likely will

11. include psychologists, other health care providers and
referral sources. There are many possible ways to enhance
your professional network, such as becoming more active
in organizations like APA and APAPO, state psychological
associations, psychological specialty societies and
local professional groups. Increasing your involvement
in relevant community groups can also be helpful for
identifying potential opportunities and expanding your
connections. Consider taking advantage of opportunities
to speak at local civic groups, participate in health-related
events or engage in other forms of community involvement.
At the same time, promoting your web presence can help
you market your services to potential clients.
Remaining flexible. The ongoing implementation of health
care reform highlights the fact that business plans need
to be updated and revised over time. Business plans are
intended to be living documents, not static blueprints. As
with all major undertakings, flexibility and persistence are
essential for meeting the challenges and taking advantage
of the professional opportunities that come your way.
Consider taking advantage of opportunities
to speak at local civic groups, participate in
health-related events or engage in other
forms of community involvement.
NOTE: The information presented
in this article is for informational
purposes only and does not
constitute legal or financial advice.
Volume 35INumber 3IJuly 2OI3iPage$ 211-227

12. Text Messaging and Private Practice:
Ethical Challenges and Guidelines for
Developing Personal Best Practices
Michael E. Sude
The impact of technology on mental health practice is currently
a concern in the counseling
literature, and several articles have discussed using different
types of technology in practice.
In particular, many private practitioners use a cell phone for
business. However, no article has
discussed ethical concerns and best practices for the use of
short message service (SMS), better
known as text messaging (TM). Ethical issues that arise with
TM relate to confidentiality,
documentation, counselor competence, appropriateness of use,
and misinterpretation. There
are also such boundary issues to consider as multiple
relationships, counselor availability, and
billing. This article addresses ethical concerns for mental health
counselors who use TM in
private practice. It reviews the literature and discusses bene fits,
ethical concerns, and guide-
lines for office policies and personal best practices.
Teehnology is evolving rapidly (Haberstroh, Parr, Bradley,
Morgan-
Fleming, & Gee, 2008) and ean help elinicians free up time and
spaee
(MeMinn, Orton, & Woods, 2008). In partieular eounselors are
using cell
phones to eonduet business (Baker & Bufka, 2011; McMinn et
al., 2008)
because they provide options for communicating with clients at

13. the clini-
cian's convenience (McMinn et al., 2008).
Cell phones can be used to connect with clients for
administrative tasks
like scheduling, cancelling, and rescheduling; to send
appointment remind-
ers; and to communicate brief thoughts or questions between
face-to-faee
(FTF) meetings. Smartphones may have the ability to connect to
the Internet
and interact with others in a variety of ways, but almost all cell
phones at least
have a text message option.
Individuals are increasingly communicating via short message
service
(SMS), better known as texting or text messaging (TM; Boschen
& Casey,
2008; Militello, Kelly, & Melnyk, 2012). TM is now used
clinically to provide
support or interventions for certain conditions and populations
(Merz, 2010).
Text messages can include pictures, videos, and text up to 160
characters
Michael £. Sude is affiliated with La Salle University and
maintains a private practice in the suburbs
of Philadelphia. Correspondence about this article can be
directed to Dr. Michael £. Sude. La Salle
University, Psychology Department, 1900 West OIney Avenue,
Philadelphia, PA, 19141. Email: [email protected]
lasalle.edu.
Journal of Mental Health Counseling 2 | |

14. (Coss & Ferns, 2010; Merz, 2010; Militello et al., 2012).
Although TM usu-
ally occurs between cell phones, messages can also be sent ftom
email and
web sites (Merz, 2010). For counselors in private practice, TM
is a low-cost
and convenient tool.
All forms of technology have ethical implications that raise
concerns
for counselors (Baker & Bufka, 2011; Baltimore, 2000; McMinn
et al., 2008;
Van Allen & Roberts, 2011; Zur, 2010). As a result, every
conversation about
using technology in practice must discuss ethics and ethical
decision-making
(McMinn et al., 2008). Centore and Milacci (2008), who studied
distance
counseling, reported that counselors experienced decreased
ability to fulfill
their ethical duties for all types of distance counseling, which
underscores
the need for training on the ethical issues in using technology in
practice.
Studies addressing best practices for specific types of
technology (Baker &
Bufka, 2011), including TM, are lacking.
This article explores TM benefits and ethical concerns for
counselors
in private practice and offers guidelines for personal best
practices. It reviews
the literature on use of technology in private practice and of TM
for clinical

15. interventions. Spécifie clinical benefits and ethical concerns are
outlined.
Although they are likely to use TM to communicate with
clients, because
private practitioners are not likely to have received technology
training,
they have the greatest need to manage ethical risks carefully. As
Bradley,
Hendricks, Lock, Whiting, and Parr (2011) said about e-mail,
my purpose is
not to decide for counselors whether or not they should use TM
in private
practice but rather to raise awareness of ethical concerns to help
them make
more informed decisions.
RESEARCH ON USE OF TECHNOLOGY IN PRACTICE
Private Practice
McMinn, Buchanan, Ellens, and Ryan (1999) conducted one
ofthe
earliest studies on use of technology in private mental health
practice (N =
429). Behaviors cited most often as unethical were
compromising client con-
fidentiality by allowing others to access client information and
conducting
any clinical services online or through email.
In another early study, Negretti and Wieling (2001) explored
issues for
marriage and family therapists (N = 42) in terms of boundaries,
being avail-
able to clients out of session, and engaging in ethical practice.
Only 50% of

16. the clinicians then surveyed used email and only 36% cell
phones, compared
to 40% who used pagers. None ofthe respondents who gave out
their email
addresses reported charging for email interactions, and only
13% who used it
warned clients about confidentiality' and privacy risks.
212
Text Messaging and Private Practice
Recently, McMinn, Bearse, Heyne, Smithberger, and Erb (2011)
exam-
ined the responses of private psychologists (N = 296) to
questions about the
ethical implications of technology use, including email, cell
phones, and
TM. Respondents most often reported using cell phones to
provide clinical
services and store client contact information, and scheduling
appointments
through email. The biggest ethical concerns were providing
clinical services
via TM and email.
Perceptions of Technology Use
Centore and Milacci (2008) surveyed clinicians about how they
used
different fypes of distance counseling. Online, real time text-
chat was
reported by 5.6% of participants and 28.1% reported using
email; of all fypes

17. attitudes toward text-chat were most negative, among them
perceptions of
decreased abilify for counselors to build rapport with clients
and decreased
abilify to assess and treat clinical issues and deal with crises.
Two studies (Haberstroh, Duffy, Evans, Cee, & Trepal, 2007;
Leibert,
Archer, Munson, & York, 2006) investigated client perceptions
of technol-
ogy-mediated counseling. Leibert et al. (2006) found that email
and instant
messaging (IM) were the most common fypes of communication
reported,
and both studies reported convenience and privacy/comfort as
benefits.
Participants in both reported that the lack of audio/visual cues
impacted
interactions, but anonymify provided safefy for self-disclosure
(Haberstroh et
al., 2007; Leibert et al., 2006).
TEXT MESSAGING AND OTHER TEXT-BASED
COMMUNIGATION
Two reviews of TM in clinical practice (Militello et al., 2012;
Wei,
Hollin, & Kachnowski, 2011) concluded that it may be a helpful
adjunct to
FTE services; however, the limitations of the few studies make
it impossible
to draw clear conclusions about its clinical effectiveness.
Recent studies
were related to crisis intervention (Coss & Ferns, 2010) and
eating disorders
(Bauer, Okon, Meermann, & Kordy, 2012; Shapiro etal., 2010).

18. TM may also
help prevent relapse after termination (Aguilera & Munoz,
2011; Shapiro &
Bauer, 2010; Shapiro et al., 2010); initiate search for mental
health services
(Coss & Ferns, 2010; Joyee & Weibelzahl, 2011); and help
individuals pursue
outpatient services after inpatient treatment (Bauer et al., 2012).
Furber et al. (2011) studied TM between youth in treatment and
thera-
pists and discovered that most of the interaction dealt with
coordinating FTF
meetings. In a small pilot study, patients in a psychotherapy
group reported
that TM helped with attendance (Aguilera & Munoz, 2011). In a
much
larger pilot study in the United Kingdom (UK), sending clients
text messages
several days before scheduled appointments improved
attendance 25-28%. If
213
the rates for the clinics studied were extended to the entire UK,
the annual
national savings would be close to US$250 million (Sims et al.,
2012).
No other published research into individual counselors sending
and
receiving text messages with clients could be found. In other
words, all the
studies listed involve programmable software that manages

19. sending text mes-
sages to certain populations or clientele at certain days and
times. Gounselors
in private practice will likely not have the training or the
software for that;
they will probably be sharing TM through their cell phones.
More research is
therefore needed on the benefits and risks of TM interactions
for counselors
in private practice.
Advantages of Text-Based Interactions
Electronic text-based interactions include TM, IM, and email,
which
all have benefits for both clients and counselors. One advantage
is flexi-
bility (Shapiro et al., 2010); text-based communication may be
used both
synchronously (immediate response) and asynchronously (lag
time between
responses; Suler, 2000). Also, the stigma of speaking with a
counselor is less-
ened because ofthe anonymity of text-only interactions (Gentore
& Milacci,
2008; Suler, 2000), which may lead clients both to be more
candid (Suler,
2000) and to experience increased ownership of the counseling
process
(Gentore & Milacci, 2008). The pace and process of writing in
asynchronous
interactions can, like journaling, help clients process and
express thoughts
and feelings (Gentore & Milacci, 2008; Haberstroh et al., 2007;
Suler,
2000). Some clients may express themselves better in writing

20. (Suler, 2000),
and text-based counseling helps clients feel less pressure about
disclosing
(Haberstroh et al., 2007; Suler, 2000).
Beyond the clinical benefits, cell phones are so common that
they
attract little attention from others, so individuals can use them
with little fear
of social stigma (Boschen, 2009; Gentore & Milacci, 2008).
TM, in particu-
lar, is widely available (Militello et al., 2012) because it costs
little (Aguilera
& Muñoz, 2011; Boschen, 2009; Boschen & Gasey, 2008;
Shapiro et al.,
2010) and does not require a smartphone (Aguilera & Muñoz,
2011). TM is
also convenient (Goss & Ferns, 2010; Shapiro et al., 2010); is
accessible at
any time (Boschen, 2009; Gentore & Milacci, 2008; Militello et
al., 2012;
Shapiro et al., 2010); and offers privacy and anonymity (Goss &
Ferns, 2010).
Individuals who are highly sensitive to others' perceptions or
reactions may
prefer a method of communicating that feels safer (Gentore &
Milacci, 2008;
Haberstroh et al., 2008; Leibert et al., 2006).
For counselors, text-based interactions are easily documented
(Suler,
2000). Haberstroh et al. (2008) reported among the clinical
advantages the
ability to review the transcript ofthe interactions during the
session to clarify

21. 214
Text Messaging and Private Practice
previous wording, and the slower pace allowing more time to
reflect on the
clinician's own responses.
TM also offers the ability to have regular contact between
sessions
(Aguilera & Muñoz, 2011) and to remind clients of skills
learned ETE to
help prevent relapse between meetings (Boschen, 2009). Eor
administrative
tasks like scheduling, cancelling, or rescheduling appointments
and sending
billing or appointment reminders, TM can save private
counselors time
beeause it can be read and responded to asynchronously
(Boschen, 2009;
Sims e t a l , 2012).
Eor some elients TM can also serve as a transitional object or a
tangible
way to remain connected to the counselor (Neimark, 2009). TM
may help
elients through the times between therapy sessions, much like
ealling a
eounselor's voice mail and leaving messages that do not need to
be returned
(Gutheil & Simon, 2005). Texts from counselors to clients also
serve as
transitional objects, similar to the letter-writing common in
narrative therapy

22. (Winek, 2010).
In family counseling, TM can help family members who
struggle to
interact with eaeh other in real time. Asynchronous TM allows
them to take
time to make meaning of messages received and to formulate
responses that
can be edited before being sent. The counselor can be eopied on
messages
between family members so that there is no eonfusion about the
words eom-
munieated, and so that there is a monitor of the communication.
Koocher
(2009) described using email with separated or divorced parents
to commu-
nicate about visitation schedules and other parenting issues.
TM has also been cited as a particularly helpful adjunct for
Gognitive-
Behavioral Therapy (GBT; Boschen, 2009; Boschen & Gasey,
2008; Shapiro
& Bauer, 2010). It can be used for self-monitoring (Boschen &
Gasey, 2008;
Shapiro & Bauer, 2010) and to report on or complete homework
(Boschen,
2009; Boschen & Gasey, 2008; Shapiro & Bauer, 2010). TM
lessens the
possible shame of carrying around paper and pen and allows
clients to
send counselors information and reeeive feedback more qui ckly
(Shapiro
et al., 2010). TM time and date stamping helps keep the
information being
exchanged more accurate than is possible with journals (Shapiro
& Bauer,

23. 2010). Messages can be sent at set times and can be helpful
when ETE or
phone contact is not possible or appropriate. Asked by TM for
information,
counselors can respond immediately, respond later, and store
communica-
tions electronically (Boschen & Gasey, 2008). Einally, as
distance counsel-
ing, TM is an option for clients who live in rural areas or cannot
leave home
because of disability or illness (Gentore & Milacci, 2008).
215
Limitations of Text-Based Interactions
One limitation is the lack of a sense of therapeutic presence
(McAdams
& Wyatt, 2010; Suler, 2000)—clients may have difficulty
feeling connected
to counselors because there are no audio or visual cues (Centore
& Milaeci,
2008; Haberstroh et al., 2007; Haberstroh et al., 2008; Siiler,
2000). They
may also feel less understood, less cared for, and less safe
(Centore & Milaeci,
2008). Text-based interactions may also lack spontaneity (Suler,
2000), and
the slower pace eould limit disclosure (Haberstroh et al., 2007).
Another limitation can be the technology itself (Haberstroh et
al.,
2007; Haberstroh et al., 2008). TM technology can fail, so that
messages are

24. never sent or received (Shapiro & Bauer, 2010). Also, some
clients may not
know how to use cell phones or be able to read messages
because of limited
eyesight, and some may be unable to afford TM (Aguilera &
Muñoz, 2011;
Shapiro & Bauer, 2010).
The main limitations of TM interactions are the ethical concerns
they
raise and the lack of regulations and ethical guidelines for best
practices.
Wliat follows addresses the guidelines that do exist and then
explores specific
issues that are important for counselors to consider if they
choose to use TM
in private practice. The last section suggests best practices for
each of the
ethical concerns raised.
Ethical and Regulatory Guidelines
Technology evolves so quickly that state regulatory boards and
profes-
sional organizations may never be able to provide guidance for
using specific
types in practice (McAdams & Wyatt, 2010; McMinn etal.,
2008; Nicholson,
2011; Van Allen & Roberts, 2011). However, some state boards
and pro-
fessional organizations do provide general guidance for doing
so (Baker &
Bufka, 2011; McAdams & Wyatt, 2010).
Bradley etal. (2011) noted that the American Mental Health
Counselors

25. Association (AMHCA) Code of Ethics (2010) is current on
providing guid-
ance for the use of technology. The seetion dedicated to
technology-assisted
counseling provides guidelines for preserving confidentiality
when transmit-
ting and storing information electronically. The AMHCA has
also published
a white paper (2012) as a companion to the Code of Ethics
(2010) that makes
recommendations for technology-assisted counseling. The white
paper
recommends, for instance, that counselors be "technologically
savvy in the
modality of communication being used," plan for crises and use
with at-risk
clients, and encrypt all text-based communication.
The American Counseling Association (ACA) Code of Ethics
(2005)
also has guidelines for counselors using technology in practice.
It addresses
confidentiality, encryption, counselor competence,
appropriateness for treat-
216
Text Messaging and Private Practice
ment, emergency protocols, expectations of responses, and
billing policies
(Bradley et al., 2011; Trepal, Heberstroh, Duffey, & Evans,
2007).

26. Furthermore, as of mid- to late-2008, 14 state boards had issued
reg-
ulations for technology-assisted counseling, and 20 more were
drafting or
discussing such regulations (McAdams & Wyatt, 2010). Ten
states have pro-
hibited technology use, and many boards have supported it
conditioned on
special circumstances (McAdams & Wyatt, 2010).
ETHICAL CONCERNS FOR PRIVATE COUNSELORS
Although counselors can currently use several types of
technology
in practice, many have little understanding of the associated
ethical risks
(McAdams & Wyatt, 2010). For eounselors using TM as an
adjunct to FTF
services, ethical concerns include confldentialify,
documentation, counselor
competence, appropriateness of use, and misinterpretation.
Boundary issues
to consider include multiple relationships, counselor
availability, and billing.
Confidentiality
The primary ethieal concern for counselors who use TM is
informa-
tion security (Bosehen & Casey, 2008; Merz, 2010) because
ofthe risk of
violating client eonfidentialify (Bradley et al., 2011; Furber et a
l , 2011; Zur,
2010). Among TM identifleation problems are not knowing
whether a elient
is alone when receiving a text, whether the client is actually the

27. one texting,
and whether someone else has access to the client phone and
saved conver-
sations (Suler, 2000). Like email (Barnett & Scheetz, 2003),
text messages
are more like postcards than private letters and, like voice mail,
clients may
assume that only counselors can access them (McMinn et al.,
1999). Also
like email (Cutheil & Simon, 2005; Van Allen & Roberts,
2011), they can
accidently be sent to the wrong person.
Portable electronics and the information stored on them can be
easily
lost or stolen (Van Allen & Roberts, 2011; Zur & Barnett,
2008), and even the
digital contact list on a counselor's cell phone can compromise
eonfidential-
ify. Finally, keeping information confidential is not completely
in the control
ofthe phone owner (Van Allen & Roberts, 2011). For example,
counselors
need to consider the risk to confldentialify if TM is intercepted
by hackers
(Merz, 2010).
Documentation
Besides protecting the information exchanged, counselors need
to
know how to securely document and store text messages.
McMinn et al.
(2008) questioned what constitutes secure password protection
or encryption
for electronic records storage and transfer, and what can be

28. done to ensure
217
that confidential information cannot be retrieved when
electronic devices
are disposed of. As clinical contacts (Zur, 2010), like e-mail
(Bradley &
Hendricks, 2009; Gutheil & Simon, 2005; Zur, 2008, 2010), text
messages
can be subpoenaed as part ofa client's file. Providers also must
be prepared
for technology "death" and have secure backup services and a
protocol for
disposing of dead technology (McMinn et al., 1999).
The counselor must give precedence to the client's rights to
privacy and
confidentiality over any personal convenience (Nicholson,
2011), and how to
do this for TM is not clear. For example, email should be
printed and placed
with notes, but it is more like a transcript than a session
summary (Gutheil
& Simon, 2005). TM is a transcript of interaction as well, but
may have less
information because of the character limits.
Counselor Competence, Appropriateness, and Misinterpretation
Beyond confidentiality, there are ethical concerns related to
counselor
competence, the appropriateness of using TM, and
misinterpretation of

29. interactions. Gounselors are rarely prepared or trained to use
technology
properly within professional relationships (Neimark, 2009; Van
Allen &
Roberts, 2011). For instance, as Haberstroh et al. (2008) noted
for online
counseling, TM leaves open the possibility of interacting with
several clients
at the same time, which can lead to distractions and mistakes.
Once counselors are trained to use TM, they will need to decide
what types of interactions to use it for. TM can be a quick way
to contact
counselors in crisis situations, any day or time, but Haberstroh
et al. (2008)
reported on situations when text-based interactions may not be
appropriate,
and self-harm was one. There are also practical barriers to the
use of TM in
emergencies. Gounselors may not receive messages immediately
or be able to
reach clients in crisis (Shapiro & Bauer, 2010), and neither
party may know
whether messages were received. In short, counselors must
determine when
and how it is appropriate to use TM with clients.
There is also a higher chance of misinterpretation,
misunderstandings,
and confusion in text-based communication, especially with
culture-specific
language and a lack of audio or visual cues (Baltimore, 2000;
Barnett &
Scheetz, 2003; Koocher, 2009). Glient difficulties with
expressing themselves
in writing (Suler, 2000) may be magnified in TM because it is

30. so hard to
explain something lengthy or complex in a limited space
(Shapiro & Bauer,
2010). Moreover, the lack of audio or visual cues may limit
ability to make
meaning of interactions, so counselors must be able to tolerate
ambiguity
(Trepal et al., 2007) and check out assumptions.
218
Text Messaging and Private Practice
Boundary Concerns
One possibility for misinterpretation is the counseling
relationship
being interpreted differently. Counselors must be careful to
avoid treating
electronic communication with clients as off the record or
casual. The possi-
bility that casual or informal interactions might lead to
boundary confusion
for clients has been explored for email (Bradley et al., 2011;
Cutheil &
Simon, 2005), and the risk is higher with TM because it is less
common in
professional relationships. Counselors may also reeeive
inappropriate mes-
sages from clients by mistake, or because TM is disinhibiting
(Suler, 2000).
Furthermore, interactions through TM can be time-consuming,
and

31. there is less time for actual exchange than in the same amount
of FTF time
(Trepal et a l , 2007). This is a consideration for billing: Should
TM be billed
per text? per minute? or how? (Zur, 2008).
Cutheil and Simon (2005) raised concerns about billing for
email inter-
actions with clients. If email contact is not billed, clients could
interpret it as
social interaction. Failure to bill for clinical emails could also
lead to issues
of countertransferenee if counselors come to feel resentful.
Furthermore,
counselors who fail to bill for email contact could be
unknowingly collud-
ing with clients to extend sessions. For example, many emails,
ranging from
long stories to seemingly easy questions expressed in one
sentence, can take
a great deal of time to read and respond to (Cutheil & Simon,
2005; Zur,
2008). This can fit for TM as well, because one limitation of
asynchronous
communication is boundary confusion around appointments
(Suler, 2000).
Time spent communicating with clients through asynchronous
communica-
tion must be established by counselors (Bradley & Hendricks,
2009; Bradley
et a l , 2011; Negretti & Wieling, 2001; Shapiro & Bauer, 2010;
Zur, 2008) in
order to model self-care and boundaries. Counselors will need
to determine
personal best practices based on how they feel about being
available outside

32. of session.
CUIDELINES FOR PERSONAL BEST PRACTICES
Van Allen and Roberts (2011) stated that newer generations of
mental
health professionals, who have grown up with modern
technology, often
are naive about its privacy, security, and professional
implications. In other
words, familiarity with technology does not mean that
counselors know how
to avoid professional problems. Clinicians tend to use new
forms of tech-
nology in practice before fully understanding the risks. They do
not need to
become experts but should understand the technology they are
using, weigh
risks as well as benefits, and make decisions in terms of
upholding ethical
codes and regulations—the ethical responsibility always lies
with the pro-
fessional (McAdams & Wyatt, 2010; Nicholson, 2011; Van
Allen & Roberts,
219
2011). The following section addresses specific issues already
raised, but first
addressed are general recommendations for private counselors
who use TM.
The basic decision private counselors must make is whether or
not to

33. use separate cell phones for their business and personal hves.
For counsel-
ors in full-time private practice, a separate business phone may
make sense
because of the volume of contacts. Part-time counselors may
choose to use
their personal cell phone to conduct business, designate their
voice mails
"confidential," and provide emergency contacts for clients in
crisis. However,
it is recommended that counselors not use personal cell phones
for clinical
practice in order to protect the data exchanged, the therapist's
privacy, and
clinical boundaries (Shapiro & Bauer, 2010).
After securing a separate business cell phone, counselors should
find
out what technology-assisted services are covered by their
hability insurance
before using the phone as an adjunct to FTF practice (Baker &
Bufka, 2011;
Bradley & Hendrieks, 2009; Bradley et al., 2011). This is vital.
Counselors
working in agencies often have guidelines for how they can and
cannot inter-
act with clients, but private counselors decide for themselves.
If covered by liability insurance, the third step is for counselors
to write
up consent policies addressing technology-assisted services
(Baker & Bufka,
2011; Barnett & Scheetz, 2003; Bradley & Hendrieks, 2009;
Bradley et al.,
2011; Merz, 2010; Negretti & Wieling, 2001; Trepal etal., 2007;
Van Allen

34. & Roberts, 2011; Zur, 2008, 2010; Zur & Barnett, 2008). Signed
client
informed consent is one ofthe clearest ways to manage risk and
limit liabil-
ity, and it allows clients to make informed choices about
clinical services.
The policies should be reviewed in a conversation at the start of
services
and periodically thereafter (Barnett & Scheetz, 2003; Bradley &
Hendrieks,
2009; Bradley et al., 2011; Merz, 2010; Trepal et al., 2007; Zur,
2008; Zur &
Barnett, 2008). Each counselor must decide what the policies
should cover.
Most state boards agree that the policies should inform clients
of what
can be expected in terms of technology-assisted services
(McAdams & Wyatt,
2010). Policies should address confidentiality (Baltimore, 2000;
Barnett &
Scheetz, 2003; McAdams & Wyatt, 2010; Trepal et al., 2007;
Zur, 2008,
2010); security measures to protect electronic information (Zur,
2010; Zur &
Barnett, 2008); how to handle emergencies (Bradley et al.,
2011; McAdams
& Wyatt, 2010; Zur, 2008); what is appropriate to send to a
counselor
electronically (Baltimore, 2000; Bradley & Hendrieks, 2009;
Zur, 2008);
appropriate times and ways to contact the therapist out of
session (Negretti &
Wieling, 2001); the times and frequencies when the therapist
will communi-
cate out of session (Bradley & Hendrieks, 2009; Bradley et al.,

35. 2011; Negretti
& Wieling, 2001; Zur, 2008); and fees or billing policies for
non-FTF contact
(Bradley et al., 2011; Negretti & Wieling, 2001; Zur, 2008).
The following
220
Text Messaging and Private Practice
subsections explore guidelines for drafting personal best
practices for these
specific ethical issues.
Confidentiality
As with email (Bradley et a l , 2011), counselors must inform
clients that
third parties may be able to access electronic interactions .
Private counselors
can do several things to help protect the information transmitted
and stored
on cell phones. Zur and Barnett (2008) provided practical
recommendations
for protecting portable electronic devices, sueh as removing
unnecessary files
when traveling, never leaving deviees unattended, and never
letting anyone
borrow them.
The SIM card in cell phones stores text messages, so password
security
for cell phones is also recommended. Furthermore, eounselors
should send

36. and read text messages in private; eell phones should have
spyware and
antivirus software to help ensure privaey (Merz, 2010); and
settings should
be adjusted so that messages do not appear when the phone is
locked. On
some cell phones counselors and elients can also set an option
to send
"read receipts" that will help both parties know whether text
messages were
received.
The use of a secure server and software that manages the texting
is rec-
ommended (Shapiro & Bauer, 2010), and any digitally stored
information
on portable devices should be without identifiable confidential
information
(Nieholson, 2011). Although it would be more convenient for
counselors to
store contacts by full names, it is recommended that they use
only initials.
Furthermore, passwords for files are insufficient; counselors
should learn
to code or enerypt confidential data stored on portable
electronic devices
(Boschen & Casey, 2008; Nicholson, 2011) and transmitted
electronically
(Trepal et a l , 2007).
Counselors can encrypt messages using technology from
cellular serviee
providers or using third parties (Merz, 2010). For smartphone
owners, apps
offer options. Both sender and receiver may need the apps to
decrypt mes-

37. sages, or only messages already sent or reeeived (stored) may
be enerypted,
leaving them unprotected during transmission.
Confirming identity in each contact is also important
(Baltimore, 2000;
Barnett & Scheetz, 2003). There is no clear way to do this
securely, but one
option is for clients to use a code word to identify themselves.
Another is for
clients to begin eaeh TM interaction by answering a question
agreed upon
at the start of services. As a general rule, a eounselor
communicating with
clients through TM should pay close attention to the client's
language to
see if it is aligned with previous TM interactions. Counselors
should also be
vigilant to double-check who the message is being sent to in
order to avoid
accidentally breaking confidentiality (Van Allen & Roberts,
2011).
221
Documentation
Counselors also need to decide how to store and document text
mes-
sages after transmission. Text messages, like voice messages
and emails, are
clinical contacts (Zur, 2010). In order to limit the information
stored on
highly portable cell phones, counselors may wish to transfer

38. stored informa-
tion. Archiving text messages involves either forwarding them
to email to be
saved or printed, taking screen shots of them with a smartphone
and then
sending them to email, or using third-party services to archive
them (Zur,
2010).
There must also be a plan for disposal of cell phones used for
therapy that
is communicated to clients (Bosehen, 2009). When disposing of
cell phones,
counselors should wipe the data from the devices by resetting or
reformatting
them (Barnett & Scheetz, 2003; Merz, 2010). Cell phone
manufacturers can
explain how counselors can erase or reformat their cell phones.
Counselor Competence, Appropriateness, and Misinterpretation
Counselors must consider their comfort level, competence with
tech-
nology, and knowledge of TM before using it in practice
(Bradley et al.,
2011; Merz, 2010). They will need to determine how TM will be
used with
each client (administrative tasks, support, intervention, etc.),
and regularly
evaluate its helpfulness (Merz, 2010). They should be trained
before using
any type of TM software, take time to learn to use the programs
properly, and
be able to troubleshoot problems (Baker & Bufka, 2011;
Bradley et al., 2011;
Merz, 2010; Shapiro & Bauer, 2010). Counselors interacting

39. with clients
through TM from home should have a designated space, sueh as
a home
office, to limit distractions and keep interactions professional
(Haberstroh et
al., 2008).
For some clients, TM may not be appropriate or helpful
(Shapiro &
Bauer, 2010). Counselors must assess whether each client can
use the tech-
nology effectively (Bradley et al., 2011). Just as counselors
must be familiar
with the technology used in practice (Negretti & Wieling,
2001), so must cli-
ents. This would include how often elients use TM in daily life,
how familiar
they are with common TM emoticons and acronyms, whether or
not they
can afford the service, and whether they have reading or
eyesight limitations.
If counselors determine that a client is competent with TM, they
can
have a conversation to decide if the client would consider TM
as an adjunct
to FTF treatment (Bosehen, 2009). In these conversations
counselors need
to address handling clinical emergencies, such as self-harm, and
discuss
emergencies, including having another way to contact the client,
and another
contact person for the client in case of emergency (Shapiro &
Bauer, 2010).
Counselors should also be aware of different ways messages

40. might be
interpreted, and discuss with clients at the start of services a
protocol for
222
Text Messaging and Private Practice
handling misinterpretation (Shapiro & Bauer, 2010). They need
to attend to
both TM content and process, be sensitive to cultural issues and
stereofypes
(Trepal et a l , 2007), and be able to process TM interactions in
FTF sessions
(Neimark, 2009).
To help limit misinterpretation, both parties may add visual
cues
through in-text graphics, spacing, punctuation, and use of caps
(Suler, 2000).
Counselors also need to become familiar with common
acronyms used in
text-based communication, such as, "LOL (laugh out loud),
ROTFL (rolling
on the floor laughing), AFK (away from keyboard)," and the use
of emoti-
cons or characters to convey emotions (i.e., :-( - sad or
annoyed; :) - happy;
"(::( )::) = a band-aid used to represent help)" (Trepal et a l ,
2007, p. 272).
Counselors can also write out their own reactions and nonverbal
responses
(i.e., « s m i l i n g » , « l a u g h i n g » , etc.; Haberstroh et a l
, 2008; Trepal et

41. a l , 2007).
Boundary Concerns
When using TM in practice, particular attention should be paid
to its
tone and the professional language. This is difficult because the
TM inter-
action is designed to be concise. Counselors should reread text
messages
before they hit "send," asking themselves whether they would
say it the same
way in an FTF session. If not, language or tone must be changed
(Cutheil
& Simon, 2005).
Counselors who receive text messages from clients that they
interpret
as out of character or unprofessional should address their
concerns with
clients in therapeutic, nonconfrontational ways (Cutheil &
Simon, 2005).
Neimark (2009) depicted a scenario in which a client texts a
clinician to say
that the previous session was "useless," and the clinician is
unsure whether or
how to respond. Counselors should discuss with clients what
information is
appropriate to exchange through TM (Shapiro & Bauer, 2010).
A counselor
who believes that a message received was inappropriate can
respond thera-
peutically by describing her or his own experience of the
message, asking
about the client's intentions, not pathologizing the interaction,
and giving

42. precedence to the client's needs.
To avoid feeling on call, counselors should also decide how
much time
they will be available through TM and communicate the
decision to clients
(Koocher, 2009; Shapiro & Bauer, 2010). As with any other
technological
adjunct, there must be clear agreement on TM boundaries and
billing poli-
cies (Boschen, 2009; Shapiro & Bauer, 2010). One option is for
clients to be
able to send messages any time, and for counselors to respond
at predeter-
mined times (Shapiro & Bauer, 2010). Similarly, Bradley et al.
(2011) sug-
gested setting a time of day to check and return emails and
setting boundaries
223
around when they are not checked or returned, such as nights
and weekends.
Presented in this way, it is made clear that TM is asynchronous
only.
Gounselors must also decide how to bill for TM because in
private prac-
tice time is money. Haberstroh et al. (2008) reported that the
slower pace of
text-based sessions meant that less material was covered than in
FTF settings,
even though counselors may spend a great deal of time
responding to short

43. TM messages or questions.
It is recommended that private counselors who agree to TM
interactions
beyond administrative tasks make clear the fee for reading and
sending each
message. For some TM plans, customers are charged per
message or given
a limited number of monthly messages. Gharging per message
read and
received is in line with many cell phone contracts, and is a more
concrete
way for counselors to set boundaries than recording time spent
reading, for-
mulating, and responding to text messages. The private
counselor thus has
the option to set boundaries around the time and energy spent
on these tasks,
knowing it will be compensated.
Training
It appears that no study has yet looked at ways graduate training
programs
address or fail to address the ethical risks of using TM in
practice. However,
several articles have called for graduate ethics courses to
address issues of
professionalism when posting on and searching the Internet
(Lehavot, 2009;
Myers, Endres, Ruddy, & Zelikovsky, 2012; Van Allen &
Roberts, 2011).
The consensus is that because they are the best way to address
ethical uses
of technology, vignettes summarizing risks and benefits of TM
use should be

44. incorporated into graduate ethics courses. Finally, the benefits
and risks of
using many forms of technology should be addressed as needed
in clinical
supervision and through professional development activities
(Lehavot, 2009;
Lehavot, Barnett, & Powers, 2010; Myers et al., 2012) for both
graduate stu-
dents and working professionals.
CONCLUSION
Technology-based counseling services will continue to grow
(Gentore
& Milacci, 2008; Haberstroh et al., 2007; McAdams & Wyatt,
2010). Rather
than closing off to new technology, it may be more effective for
mental
health counselors to learn about the benefits, risks, and ethical
issues related
to using it in practice (Barnett & Scheetz, 2003). TM is possibly
the most
inexpensive and widely available technology that can impact
mental health
treatment (Aguilera & Muñoz, 2011). It is expected to become
more popular
because of its advantages as a tool for contact between sessions,
so counselors
may need to embrace it to some degree (Merz, 2010). Distance
counseling,
224
Text Messaging and Private Practice

45. including TM, is also likely to continue to grow because it
lowers overhead
eosts and also offers counseling options for clients who cannot
access ETE
services because of where they live or their health problems
(Gentore &
Milacci, 2008). Glinicians need to inform colleagues through
professional
publieations of the benefits and challenges of using technology
so that best
practices can be formulated (MeAdams & Wyatt, 2010). Eor
private mental
health counselors using TM, this is a beginning.
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Spiritual and Religious Competencies for Psychologists
Cassandra Vieten
Institute of Noetic Sciences and California Pacific Medical
Center Research Institute
Shelley Scammell
Institute for Spirituality and Psychology
Ron Pilato

54. Sofia University
Ingrid Ammondson
Institute of Noetic Sciences
Kenneth I. Pargament
Bowling Green State University
David Lukoff
Sofia University
It is clear from polls of the general public that religion and
spirituality are important in most people’s
lives. In addition, the spiritual and religious landscape is
becoming increasingly diverse, with nearly a
fifth of people unaffiliated with a religion, and increasing
numbers of people identifying themselves as
spiritual, but not religious. Religion and spirituality have been
empirically linked to a number of
psychological health and well-being outcomes, and there is
evidence that clients would prefer to have
their spirituality and religion addressed in psychotherapy.
However, most often, religious and spiritual
issues are not discussed in psychotherapy, nor are they included
in assessment or treatment planning. The
field of psychology has already included religion and
spirituality in most definitions of multiculturalism
and requires training in multicultural competence, but most
psychotherapists receive little or no training
in religious and spiritual issues, in part because no agreed-on
set of spiritual competencies or training
guidelines exist. In response to this need, we have developed a
proposed set of spiritual and religious
competencies for psychologists based on (1) a comprehensive
literature review, (2) a focus group with
scholars and clinicians, and (3) an online survey of 184 scholars

55. and clinicians experienced in the
integration of spiritual and religious beliefs and practices and
psychology. Survey participants offered
suggestions on wording for each item, and a subset of 105
licensed psychotherapists proficient in the
intersection of spirituality/religion and psychology rated clar ity
and relative importance of each item as
a basic spiritual and religious competency. The result is a set of
16 basic spiritual and religious
competencies (attitudes, knowledge, and skills) that we propose
all licensed psychologists should
demonstrate in the domain of spiritual and religious beliefs and
practices.
Keywords: competencies, skills, spiritual, spirituality, religion,
religious
Supplemental materials:
http://dx.doi.org/10.1037/a0032699.supp
The United States is a religious and spiritual nation. Gallup
Polls
from 1992 to 2012 indicate that 55–59% of Americans say that
religion is “very important” in their lives and another 24 – 29%
say
that religion is “fairly important in their lives” (Gallup, 2012a,
p.
1). Forty percent of Americans report being “very religious and
another 29% consider themselves “moderately religious”
(Gallup,
2012b, p. 1). Further, 92% of Americans believe in God
(Gallup,
2011, p. 1).
When dealing with a serious problem, two thirds of Americans

56. prefer a psychotherapist with spiritual values (Lehmann, 1993)
and
one who integrates these values into psychotherapy (Gallup &
Bezilla, 1994). University counseling center clients have
indicated
that they would prefer to have religion/spirituality discussed
dur-
ing counseling (Rose, Westefeld, & Ansley, 2001). Therapists
report being open to discussing spiritual and religious issues
and
clients want to discuss these matters in psychotherapy (Post &
Wade, 2009). However, psychologists report discussing
spiritual-
ity and religion with only 30% of their clients, and less than
half
address clients’ spiritual or religious beliefs and practices
(SRBP)
(acknowledgments to Saunders, Miller, & Bright, 2010 for this
This article was published Online First June 17, 2013.
Cassandra Vieten, Research Department, Institute of Noetic
Sciences,
Petaluma, California, and Research Institute, California Pacific
Medical
Center, San Francisco, California; Shelley Scammell, Institute
for Spiritu-
ality and Psychology, San Rafael, California; Ron Pilato,
Clinical Psychol-
ogy Department, Sofia University, Palo, Alto, California; Ingrid
Ammond-
son, Postdoctoral Fellow, Institute of Noetic Sciences,
Petaluma,
California; Kenneth I. Pargament, Department of Psychology,
Bowling
Green State University, Bowling Green, Ohio; David Lukoff,

57. Psychology
Department, Sofia University, Palo Alto, California.
We acknowledge Alan Pierce for assistance with preparing this
article.
Correspondence concerning this article should be addressed to
Cas-
sandra Vieten, Department of Research, Institute of Noetic
Sciences,
625 Second Street, #200, Petaluma, CA 94952. E-mail:
[email protected]
.org
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Psychology of Religion and Spirituality © 2013 American
Psychological Association
2013, Vol. 5, No. 3, 129 –144 1941-1022/13/$12.00 DOI:
10.1037/a0032699
129
term) during assessment or treatment planning (Hathaway,
Scott,

62. & Garver, 2004).
Most psychologists do not receive formal training in the inter-
section of psychology and spirituality, nor on the variety of
world
religions (Hage, 2006). As most psychologists have received
little
education or training in how to attend to the religious and
spiritual
domains in clinical practice ethically and effectively (Brawer,
Handal, Fabricatore, Roberts, & Wajda-Johnston, 2002; Hage,
Hopson, Siegel, Payton, & DeFanti, 2006; Schafer, Handal,
Brawer, & Ubinger, 2011; Schulte, Skinner, & Calibom, 2002),
the
extent to and methods by which they should incorporate this
dimension into their work has been unclear.
A decade ago, only 13% of APA accredited clinical psychology
programs included any formal coursework in
religion/spirituality
(Brawer et al., 2002), and 90% of psychologists reported that
SRBP were not discussed in their academic training (Miller &
Thoresen, 2003). Though incorporation of spirituality and
religion
into supervision and coursework in APA-accredited graduate
train-
ing programs has increased since that time, still only a quarter
of
psychology training programs provide even one course in
religion/
spirituality (Schafer et al., 2011). A recent study of 292 APA-
accredited psychology training program faculty and students
indi-
cated that doctoral programs and predoctoral internships were
relying on informal and unsystematic sources of learning to pro-
vide training in religious and spiritual diversity (Vogel, 2013).

63. In
contrast, 84 –90% of medical schools offer courses or formal
content on spirituality and health (Koenig, Hooten, Lindsay-
Calkins, & Meador, 2010).
Psychologists are lagging behind other health care fields in
establishing basic spiritual and religious competencies. For
exam-
ple, more than a decade ago the American Psychiatric
Association
(Campbell, Stuck, & Frinks, 2012) began to require training in
spiritual competencies during residency, and religious and
spiritual
competencies for psychiatrists have been partially established
(Jo-
sephson, Peteet, & Tasman, 2010; Verhagen & Cox, 2010). For
more than a decade, the American Association of Medical Col-
leges (1999) has recommended that training programs:
incorporate awareness of spirituality, and cultural beliefs and
prac-
tices, into the care of patients in a variety of clinical contexts . .
. [and]
recognize that their own spirituality, and cultural beliefs and
practices,
might affect the ways they relate to, and provide care to,
patients (p.
25).
The Joint Commission on the Accreditation of Healthcare Or-
ganizations (JCAHO), which provides health care accreditation
to
more than 19,000 health care organizations in the United States,
requires a spiritual assessment as a standard element of patient
care
(JCAHO, 2008). Similar movements to establish spiritual and

64. religious competencies have been active for nurses (McSherry,
Gretton, Draper, & Watson, 2008; Pesut, 2008; van Leeuwen,
Tiesinga, Middel, Post, & Jochemsen, 2008), social workers
(Hodge, 2007), and professional counselors (Council for
Accred-
itation of Counseling & Related Educational Programs, 2009;
Miller, 1999; Robertson, 2010; Young, Cashwell, Wiggins-
Frame,
& Belaire, 2002).
In contrast, the field of psychology has yet to establish a
research-based consensus set of spiritual and religious
competen-
cies, standards for training in them, or a method for assessing
them
(Hathaway, 2008). A majority of psychologists (76%) believe
that
SRBP are currently inadequately addressed in training (Crook-
Lyon, O’Grady, Smith, Jensen, Golightly & Potkar, 2012).
How-
ever, because no formal set of spiritual and religious
competencies
for the field of clinical psychology has been established,
guidelines
for what should be included in this training are lacking.
Not Just Religious, but Spiritual
There is a need not only for religious competencies, but also for
spiritual competencies. Although the words have historically
often
been used interchangeably, spirituality and religion are increas -
ingly being viewed as distinct yet overlapping constructs
(Kapus-
cinski & Masters, 2010; Piedmont, Ciarrochi, Dy-Liacco, &

65. Wil-
liams, 2009; Schlehofer, Omoto, & Adelman, 2008; Zinnbauer
et
al., 1997). Though the term spirituality is notably missing from
the
APA Ethical Principles for Psychologists and Code of Conduct
(2010), in 2011 the APA Division 36 Psychology of Religion
was
renamed the Society for the Psychology of Religion and Spiritu-
ality, and their journal is titled the Psychology of Religion and
Spirituality (Piedmont, 2009).
Pargament (2007) has defined spirituality as “. . . the journey
people take to discover and realize their essential sel ves and
higher
order aspirations” (p. 58), or a “search for the sacred”
(Pargament,
2007, p. 52), whereas religion has been defined as “the search
for
significance that occurs within the context of established
institu-
tions that are designed to facilitate spirituality” (Pargament,
Ma-
honey, Exline, Jones, & Shafranske, 2013, p. 15). Hill et al.
(2000)
define spirituality as thoughts, feelings, and behaviors related to
concern about, a search for, or a striving for understanding and
relatedness to the transcendent. Spirituality has also been
defined
as an individual’s internal orientation toward a transcendent
reality
that binds all things into a unitive harmony (Dy-Liacco,
Piedmont,
Murray-Swank, Rodgerson, & Sherman, 2009). Kapuscinski and
Masters (2010) found that “communion with the sacred, or a
search for the sacred” (p. 194) was included in 67% of studies

66. that
provided a definition of spirituality. The word sacred most com-
monly referred to God or to the transcendent, and the authors
propose that this focus is what differentiates spirituality from
other
psychological constructs such as meaning, purpose, or wisdom.
The landscape of SRBP in the United States is rapidly shifting.
Although a majority of Americans (74%) consider themselves
Christian, a growing number identify themselves as religiously
unaffiliated (16.1% reported by Pew Forum, 2008; and 17.8%
reported by Gallup, 2012a). Fuller (2001) estimated that almost
40% of Americans were not affiliated with any church or
religion,
and approximately 20% identified themselves spiritual but not
religious. In 2003, a Gallup Poll showed that as many as 33% of
Americans identified as spiritual but not religious (Gallup,
2003).
Based on age distribution analysis, that report predicted a
contin-
ued decline in the number of Protestants and an increase in
religiously unaffiliated individuals. That prediction has been
ful-
filled. Today, 72% of millennials (18 –29 year olds) describe
themselves as spiritual but not religious (Phillips, 2010).
Clearly,
a competent psychologist must be familiar not only with
religious
aspects of client experiences, but also the less easily defined
spiritual aspects of them. Psychologists must also be aware that
many people do not engage in any religious or spiritual practice
whatsoever. Spiritual and religious competencies must include
T
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of
it
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rs

69. .
T
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s
ar
ti
cl
e
is
in
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ed
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le
ly
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pe
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70. us
e
of
th
e
in
di
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71. ed
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oa
dl
y.
130 VIETEN ET AL.
attention to and respect for lack of religious or spiritual
involve-
ment in clients as well.
Spiritual and Religious Competence as a Form of
Multicultural Competence
Three basic activities of multicultural competence are as fol -
lows: (1) to engage in the process of becoming aware of one’s
own
assumptions about human behavior, values, biases,
preconceived
notions, personal limitations, and so forth; (2) to attempt to un-
derstand the worldview of culturally different clients without
judg-
ment; (3) to implement relevant, and sensitive intervention
strat-
egies with culturally different clients (Arredondo et al., 1996;
Sue,
1998). These capacities clearly extend to cultural differences in-
volving religion and spirituality.
But, one might ask, why should training in multicultural com-
petence explicitly include spiritual and religious competencies?

72. The mere fact that many people are spiritual and/or religious
does
not necessarily indicate that psychologists should attend to this
dimension of individual difference. Prevalence alone is
insufficient
justification. For example, if a large percentage of the
population
took an interest in stock car racing, it is unlikely that
competencies
in this area would be required for practicing psychology.
First, most psychologists already recognize religion and spiri -
tuality as important aspects of human diversity (Crook-Lyon et
al.,
2012; McMinn, Hathaway, Woods, & Snow, 2009). The APA
Guidelines on Multicultural Education, Training, Research,
Prac-
tice, and Organizational Change for Psychologists (American
Psy-
chological Association, 2002) explicitly define culture as “the
embodiment of a worldview through learned and transmitted be-
liefs, values, and practices, including religious and spiritual
tradi-
tions” (p. 8). APA’s Guidelines and Principles for Accreditation
of
Programs in Professional Psychology (American Psychological
Association, 2009a) stipulate that cultural and individual
diversity
includes religion, and requires that each APA-accredited
program
“has and implements a thoughtful and coherent plan to provide
students with relevant knowledge and experiences about the role
of
cultural and individual diversity” (p. 10) and that all interns
“dem-
onstrate an intermediate to advanced level of professional

73. psycho-
logical skills, abilities, proficiencies, competencies, and knowl -
edge in the areas of . . . issues of cultural and individual
diversity”
(p. 15).
Yet the majority of work in fostering multicultural competency
focuses on ethnic and racial diversity, whereas attention to
spiritual
and religious aspects of diversity is inadequate (Frazier &
Hansen,
2009). For example, Nagai (2008) found that among clinicians
working with Asian and Asian American clients, self-ratings of
spiritual competence were significantly lower than those for
eth-
nic/racial cultural competence. Specific competencies exist or
are
in development for gender (American Psychological
Association,
2007a), sexual orientation (American Psychological
Association,
2012), aging (American Psychological Association, 2009b), and
multicultural issues (American Psychological Association,
2002).
Similar specific competencies for spiritual and religious
diversity
are needed.
Second, SRBP are important in the psychological functioning of
most adolescents and adults (Hathaway et al., 2004),
contributing
to their identity development (Fukuyama & Sevig, 2002;
Magaldi-
Dopman & Park-Taylor, 2010), worldview (Arredondo et al.,
1996; Leong, Wagner, & Tata, 1995), avoidance of risky

74. scenarios
(McNamara, Burns, Johnson, & McCorkle, 2010), and ability to
cope with difficulties (Arredondo et al., 1996). SRBP provide
meaning and support in times of stress (Oman & Thoresen,
2005;
Park, 2005) and positive religious coping has been shown to
contribute to successful stress management (Ano &
Vasconcelles,
2005; Cornah, 2006; Ironson, Stuetzle, & Fletcher, 2006; Parga-
ment, 1997; Pargament, Ano, & Wachholtz, 2005; Pargament,
Koenig, Tarakeshwar, & Hahn, 2004). More than 80% of
severely
mentally ill patients report using religion to cope (Rogers,
Poey,
Reger, Tepper, & Coleman, 2002; Tepper, Rogers, Coleman, &
Malony, 2001), and spirituality has long been recognized as a
core
component of recovery from substance use disorders (Delaney,
Forcehimes, Campbell, & Smith, 2009). Spirituality has also
been
linked to an increased sense of meaning, purpose, resilience,
satisfaction, and happiness (Fredrickson, 2002; Fry, 2000;
Parga-
ment, 2007; Pargament, Exline et al. 2013).
A robust body of empirical evidence has demonstrated benefi -
cial relationships between various dimensions of SRBP and psy-
chological health (George, Ellison, & Larson, 2002; Green &
Elliott, 2010; Koenig, King, & Carson, 2012; Miller & Kelley,
2005; Miller & Thoresen, 2003; Oman & Thoresen, 2005; Plante
& Sherman, 2001; Seybold & Hill, 2001; Wong, Rew, &
Slaikeu,
2006). In addition, interventions that have roots in spiritual
tradi-
tions have been increasingly used for treatment of depression
and

75. anxiety, as well as for enhancing psychological well-being. For
example, mindfulness-based psychotherapies have demonstrated
effectiveness for improving anxiety and mood symptoms (Hof-
mann, Sawyer, Witt, & Oh, 2010; Toneatto & Nguyen, 2007).
Dialectical Behavior Therapy and adaptations of it have shown
promise and efficacy for treating borderline, substance abusing,
eating disordered, incarcerated, and depressed populations
(Robins
& Chapman, 2004). Acceptance and Commitment Therapy has
demonstrated robust effect sizes compared to control groups
across
a number of outcomes (Powers, Zum Vörde Sive Vörding, &
Emmelkamp, 2009). Various forms of spiritually informed
cognitive– behavioral therapies have demonstrated success, in
par-
ticular with clients to whom religion is important (Waller,
Trepka,
Collerton, & Hawkins, 2010).
Third, although the majority of clinicians regard religion as
beneficial (82%) rather than harmful (7%) to mental health (De-
laney, Miller, & Bisono, 2007), the relationship between SRBP
and well-being is not consistently positive (Powell, Shahabi, &
Thoresen, 2003; Rosenfeld, 2010). There is evidence that some
spiritual and religious practices and beliefs can impair
psycholog-
ical well-being (Exline & Rose, 2005; Exline, Yali, & Lobel,
1999;
Pargament, 1997; Pargament, Murray-Swank, Magyar, & Ano,
2005). For example, scrupulosity and hyper-religiosity are
charac-
teristics of some obsessive– compulsive and psychotic disorders
(Brewerton, 1994; Greenberg, Witztum, & Pisante, 1987). The
term spiritual bypassing has been used to describe an unhealthy
misuse of religion or spiritual practices or terminology to avoid
dealing with important psychological, relationship, or global

76. func-
tioning problems (Cashwell, Bentley, & Yarborough, 2007; Cor-
tright, 1997; Welwood, 2000) Also, religious and spiritual
strug-
gles in and of themselves may require informed interventions
(Exline, 2013; Lukoff, Lu, & Turner, 1992; Lukoff, Lu, &
Yang,
2011). Both positive and dysfunctional forms of religious and
T
hi
s
do
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en
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py
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gh
te
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by
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e

77. A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s

78. al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly

79. fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no

80. t
to
be
di
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em
in
at
ed
br
oa
dl
y.
131SPIRITUAL AND RELIGIOUS COMPETENCIES
spiritual involvement are important for psychologists to
recognize
and address (Zinnbauer, 2013).
Finally, there is evidence that psychologists hold explicit and
implicit negative biases based on perceived client religiosity,
for
example, appraising religious clients as more mentally ill or
having
a poorer prognosis (O’Connor & Vandenberg, 2005; Ruff,
2008).
Perceptions of psychologist bias or prejudice against religion

81. and
spirituality may prevent utilization of services by clients who
find
these domains important, as well as limiting referrals from
clergy
or spiritual directors who fear the spiritual or religious domain
might be ignored, misunderstood or pathologized in
psychotherapy
(Richards & Bergin, 2000; Worthington & Sandage, 2002).
Active
investigation of potential biases combined with training in how
to
appropriately address spiritual and religious issues in clinical
prac-
tice should advance the field and improve the quality of clinical
practice.
Barriers to Establishing Spiritual and Religious
Competencies
A number of barriers have prevented or delayed spiritual and
religious competencies from being established in the field of
psychology. First, as a group, psychologists are considerably
less
religious than the clients with whom they work (Bergin &
Jensen,
1990; Delaney et al., 2007; Shafranske, 1996, 2000; Shafranske
&
Cummings, 2013), and have been described as antagonistic to
religion and spirituality (Hill, 2000; Plante, 2008). For example,
whereas 95% of the general population believes in God, only
66%
of psychologists do, and whereas 75% of the public agree that
their
approach to life is based on their religion, only 35% percent of
psychologists surveyed agree with this statement (Delaney et

82. al.,
2007). Because spirituality and religion are less important to
psychologists overall than their clients, they may have been ne-
glected as important aspects of multicultural competency.
Second, an emphasis on establishing psychology as a scientific
discipline may have led to a reluctance to acknowledge the rele -
vance of spirituality and religion in psychological functioning
(Coon, 1992; Miller & Thoresen, 2003; Plante, 2008), resulting
in
what Saunders, Miller, and Bright (2010) have called
“spiritually
avoidant care” (p. 355). Particularly among academic psycholo-
gists who chafe at psychology being considered a “soft”
science,
there may be hesitation to acknowledge or investigate domains
of
human existence that could potentially be viewed as
metaphysical
or supernatural.
A third barrier to establishing spiritual and religious competen-
cies has been uncertainty about their role in training or practice
(Carlson, Kirkpatrick, Hecker, & Killmer, 2002; Hathaway et
al.,
2004; Mrdjenovich, Dake, Price, Jordan, & Brockmyer, 2012).
A
consensus set of spiritual and religious competencies should
pro-
vide clearer guidelines.
Current Status of Spiritual and Religious Competency
in Psychology
At its most rudimentary level, spiritual and religious compe-
tence in psychology entails avoiding prejudice based on SRBP.

83. The American Psychological Association adopted a comprehen-
sive Resolution on Religious, Religion-Based and/or Religion-
Derived Prejudice in 2007, condemning prejudice and
discrimina-
tion against individuals or groups based on their SRBP and
resolving (among other things) to include information on
religious/
spiritual prejudice and discrimination in multicultural and
diversity
training material and activities (American Psychological
Associa-
tion, 2007b).
Beyond this, there have been primarily theoretical advances
regarding spiritual and religious competence in psychology
prac-
tice. Saunders, Miller, and Bright (2010) recommend that
psychol-
ogists engage in “spiritually conscious care” (p. 355), which
nei-
ther avoids spiritual and religious issues nor engages in
spiritual
directiveness, but instead assesses the importance of SRBP to
clients, the influence of SRBP on the presenting problem, and
the
potential of SRBP to be tapped as a psychotherapeutic resource
for
clients.
In paper presentations at the American Psychological Associa-
tion Convention, Lopez, Brooks, Phillips, and Hathaway (2005)
proposed a set of seven preliminary religious/spiritual multicul -
tural practice and diversity guidelines, including such items as
“psychologists make reasonable efforts to become familiar w ith
the varieties of spirituality and religion present in their client

84. population” (p. 1) and “psychologists are encouraged to gain
competence in working with clients of diverse
religious/spiritual
backgrounds through continuing education, consultation, and
su-
pervision” (p. 1). Likewise, Pisano, Thomas, and Hathaway
(2005)
proposed a set of eight preliminary religious/spiritual
assessment
guidelines, such as “psychologists are encouraged to routinely
incorporate brief screening questions to assess for the presence
of
clinically salient religious/spiritual client concerns” (p. 1) and
“psychologists are cautious to avoid interpreting client reports
of
attitudes or behaviors that are normative for a client’s religious
community as indicative of pathology” (p. 1).
A thoughtful set of recommendations for working with Muslim
clients that seems applicable to clients of any religious or
spiritual
tradition was proposed by Raiya and Pargament (2010),
including
(1) directly asking about the place of religion in clients’ lives,
(2)
asking what Islam means in their clients’ lives and educating
themselves about basic Islamic beliefs and practices, (3) helping
clients draw upon Islamic religious coping methods, (4)
assessing
for religious struggles and referring to a clergy member if
appro-
priate, and (5) participating in education of the Islamic public
about psychology. Delaney et al. (2009) have also offered a set
of
open-ended questions that can be used for inquiry with
substance

85. abuse treatment patients (which could be applicable to other pa-
tient populations), as well as guidelines for deciding when to
draw
upon a client’s existing spiritual resources.
Richards (2009) suggested that psychotherapists might self-
assess their level of spiritual competence by asking themselves
if
they have the ability to (1) create a spiritually safe and
affirming
therapeutic environment for their clients, (2) have the ability to
conduct an effective religious and spiritual assessment of their
clients, (3) use or encourage religious and spiritual
interventions, if
indicated, to help clients access the resources of their faith and
spirituality during treatment and recovery, and (4) effectively
consult and collaborate with, and when needed, refer to clergy
and
other pastoral professionals. Similarly, Pargament (2007)
articu-
lated four essential qualities of therapists who want to practice
spiritually integrated psychotherapy, including the following:
(1)
knowledge about religion and spirituality and how to integrate
them into treatment; (2) openness and tolerance of diverse
forms of
T
hi
s
do
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m

86. en
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ri
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e
A
m
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ic
an
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ch
ol
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al

87. A
ss
oc
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on
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on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s

88. ar
ti
cl
e
is
in
te
nd
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le
ly
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th
e
pe
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th

89. e
in
di
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to
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in
at
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br
oa
dl

90. y.
132 VIETEN ET AL.
religious and spiritual expression; (3) self-awareness of the psy-
chotherapist’s own spiritual attitudes and values; (4)
authenticity
and genuineness in relating to clients about religious and
spiritual
issues. To assess spiritual and religious competency, Nagai
(2008)
modified a number of multicultural competency measures to de-
velop the Culture and Spirituality Self Assessment (CSSA) for a
study of clinicians working with Asian American populations.
Recognizing that most spiritual competency training occurs
(though inconsistently) during internship (Brawer et al., 2002;
Russell & Yarhouse, 2006), Aten and Hernandez (2004)
identified
eight domains within which to increase supervisee SRBP
compe-
tency, including the following: (a) spiritual and religious
interven-
tion skills; (b) spiritual and religious assessment approaches
and
techniques; (c) supervisee awareness of how they influence the
assessment process; (d) cultural sensitivity to spiritual and reli -
gious differences; (e) supervisee awareness of the approach of
her
or his theoretical orientation toward spirituality and religion; (f)
case conceptualization that includes spiritual or religious
themes;
(g) development of treatment goals and plans that fit with a
client’s

91. spiritual or religious beliefs, values, and practices; and (h)
famil-
iarity with ethical guidelines that relate to spiritual or religi ous
clients and issues.
To our knowledge, none of these proposed guidelines have been
empirically validated, formally vetted by members of the field,
or
incorporated into policy. To address the lack of consensus in the
field about how spirituality and religion should be addressed in
the
practice of psychology, we engaged in a series of activities to
establish a proposed set of empirically based spiritual and
religious
competencies.
Method
Working Definitions
Kaslow (2004) defines competence as “an individual’s capabil-
ity and demonstrated ability to understand and do certain tasks
in
an appropriate and effective manner consistent with the
expecta-
tions for a person qualified by education and training in a
partic-
ular profession or specialty thereof” (p. 774). As a subset of
multicultural competencies, spiritual and religious competencies
are defined as a set of attitudes, knowledge, and skills in the
domains of spirituality and religion that every psychologist
should
have to effectively and ethically practice psychology, regardless
of
whether or not they conduct spiritually oriented psychotherapy
or

92. consider themselves spiritual or religious. Attitudes refers to
the
implicit and explicit perspectives and/or biases people hold
about
spirituality and religion as they relate to the practice of
psychol-
ogy. Knowledge refers to information, facts, concepts, and
aware-
ness of research literature psychologists should possess about
spirituality and religion as it relates to the practice of
psychology.
Skills refer to psychologists’ ability to effectively utilize their
knowledge of spirituality and religion in their clinical work
with
clients.
Participants
Participants were 184 psychologists and mental health profes-
sionals recruited through a variety of listservs and recommenda-
tions by colleagues, 105 of whom were designated as experts in
the
intersection of spirituality/religion and psychology. Experts
were
defined by being licensed clinicians, masters-level or above,
who
self-rated themselves as proficient or very proficient in the
inter-
section of religion/spirituality and psychotherapy. This number
of
participants has been suggested as appropriate for initial scale
development (Hinkin, 1998). Demographics of the sample are
provided in Table 1.
Design

93. Kapuscinski and Masters (2010) recommend both deductive and
inductive methods when creating scales relevant to religion and
spirituality, because of the wide variety of definitions of terms.
Phase I of the project involved a thorough literature review by
the
authors that informed a set of 24 provisional competencies (de-
ductive). Phase II was a half-day focus group in March 2010
with
15 experts (including psychologists, scholars, and a physician
skilled in attending to spiritual and religious issues in cl inical
practice) who discussed the content and wording of the
provisional
items (inductive), revising them in a consensus process. Expert
focus groups are a useful strategy for gaining information that
cannot be easily garnered from literature reviews and surveys/
questionnaires, because information can emerge from
interactions
through chaining and cascading of ideas in the dialogic process
(Lindlof & Taylor, 2002). In this case, focus groups were used
to
review and refine a set of provisional competencies, identify
awkward language or redundancies, and suggest important com-
petencies that had not been addressed. Phase III was a 2011
online
survey of psychologists and psychotherapists to further assess
the
content and importance of these refined competencie s. Phase
IV,
in 2012, included qualitative and quantitative analysis of
responses
and revision of items in a series of consensus building meetings,
resulting in a finalized proposed set of spiritual and religious
competencies (see Table 2).
Procedures

94. Consent was obtained from all participants, and the study was
approved by the Institutional Review Board at the Institute of
Noetic Sciences. After participants consented to participate,
they
responded to an online survey.
Measures
The online survey began with an overview of the purpose of the
project and provided working definitions of terms. Each of 24
provisional competencies was presented one at a time. First
respondents were asked to rate “Is this aspect of competency
described clearly?” by endorsing one of the following: “not
described very clearly,” “moderately clear, but could be im-
proved,” or “described very clearly.” They were then asked to
respond to the open-ended question “Do you have any sugges-
tions for changing the content or wording of this aspect of
competency?” Then, respondents were asked to assess “In terms
of your own practice of psychology, please rate the extent to
which you possess this competency,” by selecting “not at all,”
“a little,” “somewhat,” “mostly,” or “completely.” Then respon-
dents were asked to rate the relative importance of each item as
compared with others in the same category (e.g., attitudes and
T
hi
s
do
cu
m
en
t

95. is
co
py
ri
gh
te
d
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e
A
m
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an
P
sy
ch
ol
og
ic
al
A
ss

96. oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti

97. cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in

98. di
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du
al
us
er
an
d
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t
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y.