Spiritually integrated psychotherapy

1. Introduction

Version followed: Kenneth I. Pargament, Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred (Guilford, 2007) for the overall framework, updated with Pargament & Julie J. Exline, Working with Spiritual Struggles in Psychotherapy: From Research to Practice (Guilford, 2021) for struggle assessment and treatment, and with Pargament and Exline's own APA Science Brief on religious and spiritual struggles (2020). Session-level procedures come from the manualised programmes evaluated by Pargament's group, mainly Winding Road (a 9-session group for students with spiritual struggles) and Solace for the Soul (8 individual sessions for adult survivors of sexual abuse). The two books are cited through the publisher's contents pages and descriptions; chapter-level detail inferred from chapter titles is marked [uncertain]. [source: Guilford book pages; APA Science Brief 2020; kennethpargament.com; UCLA Winding Road article; Psychiatry & Psychotherapy Podcast ep. 138]

What it is. Spiritually integrated psychotherapy (SIP) is a framework and orientation, not a single manualised therapy. It is a way of bringing the sacred dimension of clients' lives into any psychotherapy. The publisher describes it as nonsectarian, covering both traditional and nontraditional spirituality, and as drawing on psychotherapy research, the psychology of religion and clinical cases. In Pargament's account, spirituality can be part of the client's problem and also part of the solution. Clinically, SIP has three tasks: (1) start a spiritual dialogue, (2) assess spirituality, and (3) help clients draw on spiritual resources and address spiritual problems. [source: Guilford 2007 description and contents]

How change happens (in the authors' model). In this model, spirituality is part of a person's search for significance. That search is guided by an orienting system of beliefs, practices, ways of regulating emotion and relationships. What a person holds sacred can include God or a higher power. It can also include anything the person invests with sacred qualities, such as nature, vocation or relationships, so non-religious clients can have spiritual concerns too. Under stress, people use spiritual coping either to conserve the sacred or to transform it. Problems arise in spiritual destinations (what is held sacred) and spiritual pathways (how it is pursued). Pargament and Exline treat spiritual struggles as forks in the road that can lead to decline or to growth. In their account the outcome depends on access to resources, the capacity to accept what cannot be changed, and a cohesive, authentic guiding vision. Therapy aims to tip that fork toward growth. [source: Guilford 2007 contents; Guilford 2021 description; Podcast ep. 138]

2. Framework

The 2007 book orders the clinical work as a sequence: orientation, then initial and implicit assessment, then explicit assessment, then drawing on resources, then addressing problems of destinations and pathways. These are not fixed phases with session counts. They are a clinical progression that runs inside the therapist's existing modality. [source: Guilford 2007 contents] The stage goals and transition criteria below are inferred from that order and from the manualised programmes. [synthesis]

[source: Guilford 2007 contents; UCLA Winding Road article; Family Practice News 2005 on Solace for the Soul; kennethpargament.com training and evaluation pages]

Notes on format:

• Individual therapy: no fixed length. SIP adds to, and does not replace, the clinician's primary treatment. The developer of Solace for the Soul described it as an adjunct to other therapy and said it cannot fully heal abuse on its own. [source: Family Practice News 2005]
• Group (Winding Road): 9 sessions of 90 minutes, run under a manual. Each session has an opening and closing ritual, experiential exercises, discussion, readings and music, plus between-session "Spiritual Enhancement Exercises" and resource lists. The group was nonsectarian and its members held diverse beliefs (Protestant, Catholic, Wiccan, atheist, agnostic). [source: UCLA Winding Road article]
• Measurement: the programmes tracked symptoms (e.g., the Brief Symptom Inventory) alongside spiritual measures (religious coping, God image, spiritual struggle) at baseline, mid-point, end and follow-up. [source: UCLA; Family Practice News 2005]

3. Guiding principles

• Spirituality is a legitimate life domain. Treat it like the social, psychological and biological domains: assess it and work with it routinely, not only when the client raises it. [source: Podcast ep. 138; Guilford 2007]
• Spirituality can be both problem and solution. Assess for resources and for struggles in the same client. [source: Guilford 2007 description]
• Nonsectarian and inclusive. Apply the approach to traditional religion, nontraditional spirituality, and secular "sacred" objects such as nature, vocation and relationships. Atheist and agnostic clients are included. [source: Guilford 2007; Podcast ep. 138; UCLA]
• Follow the client's lead, language and meaning. Use the client's words for the sacred, and never assume you share their theology. [source: Podcast ep. 138]
• Ask; don't assume. Ask how this client reconciles suffering with their beliefs (theodicy). Traditions, and individuals within them, answer this differently. [source: Podcast ep. 138]
• Avoid neglect and avoid overcorrection. Ignoring spirituality is an error. So are imposing anti-religious views (e.g., advising the client to leave their faith, or assuming all religious involvement is toxic), proselytising, and acting as clergy or drawing theological conclusions for the client. [source: Podcast ep. 138]
• Know the limits of psychotherapy. Help clients reach spiritual and religious resources outside therapy when appropriate, such as community, clergy or spiritual direction. [source: Podcast ep. 138]
• Willingness, courage and curiosity are the core competence. The authors say no specialised theology is needed; what is needed is the "willingness, courage, and curiosity" to engage. [source: Podcast ep. 138]
• Therapist self-knowledge. Write your own spiritual biography, look at your own struggles (including in your own therapy), and check your biases about religion. A "religiosity gap" between therapists and clients is common. [source: Podcast ep. 138]
• Normalise struggle; destigmatise doubt. Spiritual struggles are presented as a normal part of development, not a failure of faith. [source: UCLA Winding Road; Guilford 2021 description]
• Struggles are forks in the road. Aim to move them toward growth, not to remove them. Resolution is not a required outcome. [source: Guilford 2021 description; UCLA]
• Stay with charged emotion. Make room for anger at God, a religious community or others without judging it, and do not change the subject because you are uncomfortable. [source: Podcast ep. 138]
• Use ruptures. Disagreements about religion or politics in session are opportunities for repair and change. [source: Podcast ep. 138]
• Respect the client's view of the sacred. Programmes do not prescribe one God image or definition of the sacred. [source: Family Practice News 2005; UCLA]
• Integrate, don't replace. Spiritual interventions are combined with standard methods (e.g., cognitive work in Solace for the Soul) and with standard risk management. [source: Family Practice News 2005] [synthesis on risk management]

4. Intervention inventory

This inventory has four groups: A, assessment; B, drawing on spiritual resources; C, working with spiritual struggles and problems; D, the therapist's own preparation. Items 4.1–4.2 and 4.7–4.11 follow the chapter titles of Pargament (2007). The detailed steps inside them are [synthesis], because the chapters' own procedures are not given in the sources used. Items from Winding Road and Solace for the Soul follow the published session lists. All step-by-step wording is my own. All example language is (illustrative).

A. Assessment

4.1 Initial and implicit spiritual assessment

• Purpose / when: From the first session with every client. The aim is to show that the sacred can be discussed and to notice spiritual themes before using explicitly religious language. [source: Guilford 2007 contents, ch. 10 title] What "implicit" covers in Pargament's chapter was not verified [uncertain].
• Steps [synthesis]: (1) Add one or two open questions about meaning and sources of strength to the standard intake. (2) Listen for words that carry sacred weight: "blessed", "cursed", "meant to be", "my calling", "unforgivable", "God", "the universe". (3) Reflect the theme back in the client's own words and see whether they open it up or close it down. (4) Note whether spirituality seems linked to the problem, to coping, or to neither. (5) Make no judgement yet about whether it helps or harms.
• Example language (illustrative): "What has kept you going through this?" "When you say this feels like a punishment, what's that like for you?" "Some people find faith, spirituality or something bigger than themselves matters in times like this. Is anything like that part of your life?"
• Watch for: Hesitation that may come from fear of being judged as "too religious" or "not religious enough" (the authors list clients' fear of bias, guilt and shame as barriers). Also watch your own urge to skip the topic. It is working when the client brings in meaning or faith material without being prompted. [source: Podcast ep. 138]

4.2 Explicit spiritual assessment

• Purpose / when: Once the client has signalled that spirituality matters, whether as a resource or a source of pain, or when the presenting problem involves loss, trauma, moral injury, illness, guilt or a crisis of meaning. [source: Guilford 2007 contents, ch. 11 title] [synthesis on indications]
• Steps [synthesis, structured on the authors' model]: Map, in conversation: (1) What is sacred to the client: God or a higher power, or sanctified parts of life such as family, nature or work. (2) Pathways: practices, community, beliefs and moral code. (3) Coping: under this stressor, is the client trying to conserve the sacred (hold on, rely on practices, seek support) or transform it (re-evaluate, change their understanding, convert, leave)? (4) Struggles: screen all six types (4.3). (5) Fit: is the spirituality helping, hurting, or both? (6) Agree with the client whether and how spiritual material will be part of treatment goals.
• Example language (illustrative): "How does what you believe, or what you hold sacred, connect with what brought you here?" "Has this changed how you see God, your faith or what matters most?" Pargament has suggested a direct opener for new clinicians. In paraphrase, it asks how problems with religious or spiritual communities and ideas are affecting the client's mental health. [source: Podcast ep. 138]
• Watch for: Assuming you share the client's theology. Treating spiritual language only as a symptom. Imposing your own frame. It is working when the client and you can describe together how spirituality interacts with the presenting problem.

4.3 Screening the six types of spiritual struggle

• Purpose / when: In explicit assessment, and whenever distress carries spiritual content. Pargament and Exline define struggles as "experiences of tension, conflict, or strain on whatever people view as sacred". [source: Podcast ep. 138]
• Steps: Ask in turn about each type. (1) Divine: anger or disappointment with God; feeling punished, abandoned or unloved. (2) Demonic: attributing problems to the devil or evil spirits, or feeling tormented by them. (3) Interpersonal: conflict with people or institutions over sacred matters. (4) Doubt: confusion and troubling questions about beliefs. (5) Moral: guilt about falling short of one's standards, or difficulty following them. (6) Ultimate meaning: whether life has meaning or matters at all. Then ask how the types interact. In the authors' example, anger at God leads to leaving the faith, which then brings interpersonal, doubt and meaning struggles. [source: Podcast ep. 138; Guilford 2021 contents]
• Example language (illustrative): "Some people in your situation feel angry at God, or abandoned. Has anything like that come up?" "Do you find yourself wondering whether any of this means anything?" "Is there anyone, or any group, you're in conflict with over faith or values?"
• Watch for: Struggles are common. In the US surveys the authors cite, moral and meaning struggles were the most frequently reported, so ask about them routinely. Treat demonic attributions carefully (see 4.16 and section 5). It is working when the client names a struggle without having to defend it. [source: Podcast ep. 138]

4.4 Standardised spiritual measures (optional)

• Purpose / when: To add to the interview and to track change. Pargament's group has used: the Religious and Spiritual Struggles (RSS) Scale (Exline, Pargament and colleagues), which covers the six struggle types; the Brief RCOPE (a brief measure of positive and negative religious coping); a God Image Scale; and a religious concepts survey. These were used alongside symptom measures such as the BSI and the Trauma Symptom Checklist-40. Pargament's website also has a "Measures" page. [source: academia.edu Pargament profile; Family Practice News 2005; kennethpargament.com navigation]
• Steps [synthesis]: Give the measure at intake. Discuss high-scoring areas with the client rather than only scoring them. Repeat at mid-point and at the end, as the programmes did.
• Watch for: Items reproduced here would breach copyright, so get the instruments from their authors. Scores open a conversation and do not replace it.

4.5 Spiritual autobiography

• Purpose / when: Early in therapy or group work, to see the client's spiritual history as a story: formative experiences, turning points, wounds, resources. It was the core activity of Winding Road session 1 ("Starting Down the Winding Road"). [source: UCLA Winding Road article]
• Steps [synthesis of the published activity]: (1) Invite the client to tell or write the story of their spiritual life from childhood to now, including periods of absence or rejection. (2) Suggest marking high points, low points and turning points. (3) In session, explore the client's current relationship to each period. (4) Link the patterns to the presenting problem.
• Example language (illustrative): "Could you tell me the story of your spiritual life, or your life with or without faith, from as early as you remember? The doubts and the times you walked away count too."
• Watch for: Disclosures of religious or clergy abuse. Shame about "backsliding". It is working when the client sees continuity or a trajectory rather than isolated failures.

4.6 Spiritual genogram

• Purpose / when: To trace spiritual heritage across generations: beliefs, practices, conversions, conflicts, losses. It was the activity of Winding Road session 3 ("Understanding Your Spiritual Heritage"). [source: UCLA Winding Road article]
• Steps [synthesis]: (1) Draw a standard three-generation genogram. (2) Add each person's religious or spiritual identity, practices and notable spiritual events (conversion, leaving, mixed marriage, persecution). (3) Mark alliances and conflicts that run along spiritual lines. (4) Ask the client what they inherited, what they rejected, and what they want to keep.
• Example language (illustrative): "Where does your sense of right and wrong, or of God, come from in your family? Who in your family would understand your questions?"
• Watch for: Family conflict over the client's beliefs (an interpersonal struggle). It is working when the client can tell their own spirituality apart from family expectations.

B. Drawing on spiritual resources

4.7 Drawing on spiritual strivings: ideal spiritual self and "strengthening your wings"

• Purpose / when: To connect treatment goals with the client's sacred strivings, which are what they ultimately seek. [source: Guilford 2007 contents, ch. 12 title] Winding Road session 4 ("Your Spiritual Self") used a visualisation of an ideal future spiritual self and the values that lead there. Its homework, "Strengthening your wings", meant actively using spiritual resources toward one's goals. [source: UCLA Winding Road article]
• Steps [synthesis of published activities]: (1) After a brief settling, guide the client to imagine themselves some years ahead, living in line with what they hold sacred. (2) Ask them to describe that self's values, relationships and daily practices. (3) Identify two or three values that lead there. (4) Agree one concrete weekly action that draws on a spiritual resource and moves toward a current goal. (5) Review it next session.
• Example language (illustrative): "Picture yourself a few years from now, the person you'd most hope to become spiritually. What do they value? How do they spend their mornings? What's one step toward them this week?"
• Watch for: Perfectionistic or punitive ideals, which can feed moral struggle. It is working when the client's behaviour lines up more with their values (an outcome Winding Road measured).

4.8 Drawing on spiritual knowledge and experience; sacred objects

• Purpose / when: To reconnect the client with what they know and have experienced of the sacred (memories of transcendence, texts, teachings) as a source of meaning and strength. [source: Guilford 2007 contents, ch. 12 title] Winding Road session 5 ("Sizing Up Your Sacred") had participants bring and share an object representing their sense of the sacred and view a slideshow of sacred images and concepts. The purpose was to widen how participants think about God and the sacred. [source: UCLA Winding Road article]
• Steps: (1) Ask the client to bring an object, image, text or piece of music that stands for what is sacred to them. (2) Explore what it represents, when it became meaningful, and what it says about their view of the sacred. (3) In a group, invite each member to share and others to listen without evaluating. (4) [synthesis] Gently explore whether their image of the sacred is large enough to hold their current suffering.
• Example language (illustrative): "Tell me about what you brought. What does it hold for you?" "Has your sense of God, or of what's sacred, grown or shrunk through this?"
• Watch for: Comparing traditions or ranking them in groups. The therapist evaluating theology. It is working when the client's view of the sacred becomes more flexible and less threatening (Winding Road participants reported feeling more acceptance from God). [source: UCLA]

4.9 Spiritual practices: meditation, loving-kindness, prayer and ritual (client-led)

• Purpose / when: To use practices the client already values, or is open to, for emotion regulation, connection and meaning. [source: Guilford 2007 contents, ch. 13 title] Documented uses in Pargament's group: loving-kindness meditation toward self and others (Winding Road session 6 and weekly homework); opening and closing rituals in each group session; and a study of whether a spiritual framing of meditation matters for migraine (Wachholtz & Pargament 2008, "Migraines and meditation: Does spirituality matter?"; its protocol is not described here [uncertain]). [source: UCLA; kennethpargament.com evaluation page]
• Steps [synthesis]: (1) Ask which practices the client uses or has used, and how they feel about them now. (2) Choose a practice with the client that fits their tradition, or a secular one. (3) Rehearse it briefly in session. (4) Set a small home-practice plan. (5) Review its effects and adjust.
• Example language (illustrative): "You mentioned you used to pray when you were anxious. Would it fit to bring that back, or does that feel complicated right now?"
• Watch for: Never prescribe a religious practice the client doesn't hold, and never lead prayer in a way that imposes your faith. A practice can become a compulsion or a punishment (e.g., scrupulous prayer); if so, move to 4.11/4.15. Meditation can bring up anxiety or traumatic material in some clients; stabilise first [synthesis]. It is working when the practice brings calm, connection or meaning rather than more guilt.

4.10 Spiritual relationships and community

• Purpose / when: To mobilise supportive relationships linked to the sacred, such as a congregation, spiritual director, clergy or like-minded peers, and to reduce isolation. [source: Guilford 2007 contents, ch. 13 title; Podcast ep. 138 on helping clients access resources beyond therapy] Winding Road participants said they felt less alone and less judged after sharing in a group. [source: UCLA]
• Steps [synthesis]: (1) Map the client's spiritual network: who supports them and who wounds them. (2) Identify one safe contact. (3) With written consent, offer to consult or collaborate with the client's clergy or spiritual director on the spiritual questions, leaving theology to them. (4) For clients alienated from their community, explore alternatives such as other communities, groups or a spiritual director.
• Example language (illustrative): "Is there anyone in your faith community you could talk to about this, or someone you'd want me to talk to, with your permission?"
• Watch for: Pushing the client back into a community that harms them, or away from one that supports them. Both are errors. It is working when the client has at least one relationship where their spiritual life can be spoken about.

4.11 Spiritual coping methods: conserving and transforming

• Purpose / when: To strengthen helpful spiritual coping and to recognise when conserving coping has stopped working and transformation is needed. [source: Guilford 2007 contents, chs. 5–6 and 13 titles]
• Steps [synthesis]: (1) Use 4.2/4.4 to name the client's current spiritual coping, both helpful (e.g., seeking support from God or community, finding meaning, collaborative problem-solving with the sacred) and harmful (e.g., seeing the stressor as divine punishment, passive deferral). (2) Reinforce what helps. (3) Where conserving efforts fail and distress grows, explore openly whether the client's understanding of the sacred may need to change. Frame this as a possible path of growth, not as loss of faith. (4) Respect the client's decision about which way to go.
• Example language (illustrative): "Holding on to your faith the way you always have seems to be costing you a lot right now. What would it mean to let your understanding grow, if that's possible within your tradition?"
• Watch for: The therapist steering transformation toward their own worldview. It is working when the client's coping is more flexible and their distress falls.

C. Working with spiritual struggles and problems

4.12 Naming and normalising struggles (sharing struggles)

• Purpose / when: As soon as a struggle is identified. The aim is to reduce stigma, isolation and shame. This was the focus of Winding Road session 2 ("Sharing Spiritual Struggles"). The programme's stated aims included helping members put their struggles into words and normalise them. [source: UCLA Winding Road article]
• Steps: (1) Invite the client to describe the struggle in full: thoughts, feelings, and when it is worst. (2) Reflect it without correcting it. (3) Offer normalising information: the authors cite surveys in which roughly three-quarters of people report some spiritual struggle. (4) Frame the struggle as a fork in the road and not as proof of failure. (5) In groups, members share in turn and others listen without advising. [source: UCLA; Podcast ep. 138; Guilford 2021 description]
• Example language (illustrative): "What you're describing is far more common than people say out loud. Struggling with God or with faith doesn't mean you've failed at it. Often it's a turning point."
• Watch for: Strong emotions are common. Winding Road members described terror, panic, hopelessness and suicidal thoughts, so assess risk (section 5). It is working when the struggle feels "smaller" and less overwhelming, as participants reported. [source: UCLA]

4.13 Divine struggles: making room for anger, and the "two-way lament"

• Purpose / when: For clients who feel anger at God, or feel punished, abandoned or unloved by God. [source: Podcast ep. 138; Guilford 2021 contents] Winding Road session 8 ("Meaning Making: Seeing the Road from Another Point of View") used a group "two-way lament": members voiced their struggles, then each reflected individually on how God might respond. [source: UCLA Winding Road article]
• Steps: (1) Give explicit permission to express anger, bitterness and grief toward God without judgement. Stay with it and do not change the subject. [source: Podcast ep. 138] (2) [synthesis of published activity] Invite the client to write or speak a lament addressed to God (or the sacred) saying what hurts. (3) Then invite the client to write or imagine a response from God as they understand God at their best, in their own tradition's terms. (4) Explore both parts: what was it like to say it, and what came back? (5) Ask, without assuming, how the client's tradition makes sense of suffering (theodicy).
• Example language (illustrative): "It's all right to be angry with God here. You don't have to tidy it up for me." "If you wrote down everything you want to say to God about this, what would you say? And what do you imagine might come back?"
• Watch for: Clients for whom addressing God in this way is forbidden by their tradition; in that case, adapt it, for example as a written lament or with input from clergy. The response the client imagines may be harsh; if so, explore where that voice comes from (see 4.17). It is working when the client feels less abandoned and more accepted (as Winding Road participants reported) or can hold the anger without spiralling. [source: UCLA]

4.14 Forgiveness work (self and others)

• Purpose / when: For resentment toward others (including religious figures or a former partner) or self-condemnation. Winding Road session 6 was "Forgiveness: A Bridge to Wholeness", using loving-kindness meditation toward self and others. Rye, Pargament and colleagues (2005) ran a randomised trial of group interventions to help people forgive an ex-spouse; its session content is not described here [uncertain]. [source: UCLA; kennethpargament.com evaluation page]
• Steps [synthesis of published activity]: (1) Separate forgiveness from condoning, reconciling or forgetting. (2) Explore the hurt in full first. (3) Guide a loving-kindness practice, starting with self or a benefactor and moving gradually toward the person who caused harm only when the client is ready. (4) Assign daily practice. (5) Explore what releasing resentment, or not releasing it, would mean for the client spiritually.
• Example language (illustrative): "Forgiving doesn't mean what happened was OK, or that you have to let them back in. It's about what you carry. Where would you want to start: with yourself, or with someone else?"
• Watch for: Pressure to forgive, especially from a religious community in abuse cases, can retraumatise. Forgiveness is offered as an option, not a requirement [synthesis]. It is working when the client moves toward acceptance of self and others, which was a stated aim of Winding Road. [source: UCLA]

4.15 Acceptance and surrender ritual

• Purpose / when: When the client is fighting what cannot be changed. Winding Road session 7 ("The Path to Acceptance") used a surrender ritual: participants placed the things they could not control into a bowl at the centre of the circle. In the authors' model, the capacity to accept difficult circumstances helps steer a struggle toward growth. [source: UCLA; Podcast ep. 138]
• Steps [synthesis of published activity]: (1) With the client, list concerns and sort them into what they can and cannot influence. (2) Write each uncontrollable concern on a slip of paper. (3) Invite a symbolic act of placing it in a bowl, or of giving it over to God or the sacred if that fits the client's beliefs. (4) Process what letting go felt like and what remains. (5) Agree actions for the controllable items.
• Example language (illustrative): "Which of these are yours to carry, and which are not? Would it mean anything to you to set these ones down, here, symbolically?"
• Watch for: Surrender used to avoid action that is actually possible (e.g., leaving an abusive situation). Rituals that clash with the client's tradition. It is working when rumination about uncontrollable matters decreases.

4.16 Doubt, moral, interpersonal, demonic and ultimate-meaning struggles

The 2021 book has a chapter on each of these struggles. In their APA Science Brief, Pargament and Exline define the six types: divine (anger or disappointment with God, feeling punished or abandoned by God), demonic (worry that problems come from the devil or evil spirits), doubt (distress over religious questions), moral (guilt about falling short of one's own standards), ultimate meaning (concern that life may not matter) and interpersonal (conflict with people or institutions over sacred matters); the types often occur together. The brief gives general guidance rather than type-specific procedures: ask about struggles during assessment, normalise them, invite reflection on how they relate to mental health, help clients find resources, and consult or collaborate with clergy when appropriate. An accepting attitude, seeing the struggle as a chance for positive change, finding meaning in it, religious or spiritual coping and a sense of ultimate hope are linked with growth. [source: APA Science Brief 2020] The specific procedures below are therefore [synthesis] built on these definitions and that stance. [source: Guilford 2021 contents; Podcast ep. 138]

• Doubt: Treat questions as legitimate exploration. Winding Road encouraged participants to explore hard questions without stigma and did not aim to resolve them. Help the client tolerate not knowing, look into their questions (reading, conversation with a trusted teacher), and separate doubt from moral failure. [source: UCLA] Illustrative: "What would it be like to let the question stay open for a while?"
• Moral: Pargament's group has evaluated a manualised intervention for moral spiritual struggles, "From Vice to Virtue" (Ano, Pargament, Wong & Pomerleau, 2017) [source: kennethpargament.com evaluation page]. Its session content is not described in the sources used [uncertain]. [synthesis] Explore the standard the client feels they have violated, distinguish guilt (behaviour) from shame (self), consider repair and amends, draw on the tradition's own resources for confession, atonement or forgiveness, and watch for scrupulosity (consider OCD treatment).
• Interpersonal: For conflict with family, congregations or institutions over sacred matters. Validate the hurt without condemning the whole community. Explore boundaries, alternative communities and, where the client wants it, repair. [synthesis; stance from Podcast ep. 138]
• Demonic: Take the client's experience seriously, use their language, and explore what the attribution means to them and what it protects against. Assess carefully for psychosis, trauma-related phenomena and dissociation. Do not perform or recommend deliverance or exorcism; with consent, involve the client's own religious authority for the religious question. [synthesis]
• Ultimate meaning: Use meaning-making work. Winding Road session 8 used the theme of "seeing the road from another point of view". Explore what has mattered, what matters now, and where meaning may lie in the struggle itself. Assess suicide risk when the client expresses hopelessness about life's meaning. [source: UCLA] [synthesis on steps]

4.17 Working with negative spiritual images in trauma (Solace for the Soul)

• Purpose / when: For survivors of sexual abuse whose negative spiritual images (e.g., being worthless or undeserving of love before God) sustain shame, depression, PTSD, and body-image and sexual difficulties. The programme was an 8-week, individual, manualised intervention combining cognitive therapy with spiritual exploration. It was nondenominational but theistic, and the sacred could be understood broadly (as nature, energy or a deity). Murray-Swank & Pargament evaluated it in 2005 ("God, where are you?"). [source: Family Practice News 2005; kennethpargament.com evaluation page] Session detail beyond the news report is [uncertain].
• Session themes (as reported): (1) abandonment by God and the anger that goes with it; (2) connecting with the spiritual; (3) letting go of shame; (4) the body as a beautiful creation; (5) sexuality as sacred and life-affirming. Clients also kept daily logs of spiritual and psychological distress, coping, self-worth and trauma symptoms. [source: Family Practice News 2005]
• Steps [synthesis, integrating cognitive methods]: (1) Identify the client's spiritual self-images and God images linked to the abuse. (2) Examine them as you would cognitive beliefs: where they came from (often the abuser's or an abusive community's messages), the evidence, and their effect. (3) Help the client build alternative images drawn from their own tradition's resources or their own experience of the sacred. (4) Do body-image work, such as writing positive statements about the body. (5) Approach sexuality themes last and gradually.
• Example language (illustrative): "Where did you first learn that God saw you that way? Whose voice does that sound like?"
• Watch for: Sessions on the body and sexuality were the hardest, some participants could not yet write any positive statements about their body, and sexual symptoms rose at times during the programme. The developer noted that healing may feel more painful during the process. Use it as an adjunct within trauma-focused care. [source: Family Practice News 2005]

4.18 Using ruptures and transference around religion

• Purpose / when: When disagreement, misunderstanding or a false assumption of shared meaning about religion (or politics) comes up between therapist and client. [source: Podcast ep. 138]
• Steps [synthesis]: (1) Notice the shift: the client goes quiet, defends, or tests your views. (2) Name it gently. (3) Ask what the client imagines you think. (4) Acknowledge any misattunement on your part. (5) Explore links to the client's experience of religious figures or authority.
• Example language (illustrative): "I wonder if what I said about your church landed as criticism. Did it?"
• Watch for: Your own discomfort. Both of you may feel unsafe. It is working when the alliance deepens and the client brings in more spiritual material.

4.19 Group rituals: opening, closing and ending ceremonies

• Purpose / when: In group programmes, to create a sense of the sacred and of containment. Every Winding Road session had opening and closing rituals, and the final session closed with a candle-lighting "fire ceremony" in which members shared reflections and hopes. [source: UCLA]
• Steps [synthesis]: Keep rituals simple and non-sectarian (e.g., a moment of silence, a reading chosen in rotation, lighting a candle). Let members opt out without explanation.
• Watch for: Rituals that feel like worship in a tradition some members don't share. Never borrow ceremony from Indigenous or other religious traditions you have no authority to perform. [synthesis]

D. Therapist preparation

4.20 Spiritual self-assessment and competency training

• Purpose / when: Before and during SIP work. [source: Podcast ep. 138; kennethpargament.com]
• Steps: (1) Write your own spiritual biography. (2) Look at your own spiritual struggles, including in personal therapy. (3) List your assumptions and biases about religions and about non-belief. (4) Train: Pargament's site points to Spiritual Competency Training in Mental Health, an eight-session online course (edX). (5) Seek consultation for cases outside your cultural or religious knowledge.
• Watch for: A "religiosity gap" between you and your clients that leads you to underestimate spirituality, or a shared faith that leads you to over-identify. [source: Podcast ep. 138] [synthesis on over-identification]

4.21 Addressing problems of spiritual destinations and pathways

• Purpose / when: When the problem lies in what the client holds sacred (destination) or how they pursue it (pathway), rather than in a passing struggle. [source: Guilford 2007 contents, chs. 7–8, 14–15 titles] A reviewer of the book highlighted its attention to a "stunted and stagnant" spirituality as a contributor to distress. [source: Guilford 2007 print page, PsycCRITIQUES review] Pargament's own criteria for these problems are not given in the sources used [uncertain].
• Steps [synthesis]: (1) Destination problems: explore whether something has been made sacred in a way that harms the client or others, such as sanctifying a relationship, career or substance so that losing it feels like losing everything. Also look for an image of the sacred too small or punitive to hold the client's life. Help the client widen or rebalance it. (2) Pathway problems: explore whether the client's practices and beliefs are too narrow (one method for everything), too rigid (unable to adapt to new circumstances), poorly matched to the problem, or inconsistent with what they value. Collaboratively test alternative practices. (3) Connect to 4.8 (widening the sacred) and 4.11 (transforming coping).
• Example language (illustrative): "When this relationship ended, it sounds like it took your whole sense of what life is for with it. What else has ever felt that important?" "Your way of praying has been the one tool for everything. What might it look like to have a few more?"
• Watch for: The therapist defining for the client what the "right" sacred is. It is working when the client's spirituality becomes more flexible and better integrated with the rest of their life.

5. Handling problems

Unless marked otherwise, the guidance in this section is [synthesis]. The sources address mainly therapist avoidance, overcorrection, ruptures and emotional intensity.

• Therapist avoidance of spiritual material. This is the most common failure. The authors trace it to anti-religious traditions in the field, lower religiosity among clinicians, fear of overstepping, and lack of training. Response: add one routine question to every intake (4.1), do 4.20, and seek consultation. [source: Podcast ep. 138]
• Overcorrection: imposing, proselytising or acting as clergy. Response: check whether each intervention is the client's goal in the client's language. Hand theological questions to the client's own religious authority. Don't advise the client to leave or join a faith. [source: Podcast ep. 138]
• Client reluctance to discuss spirituality (fear of being judged, shame, past bad experiences with professionals, or simply no interest). Response: name the possible fear, make clear you are neutral and curious, offer the topic once and leave the door open. A client who isn't interested is respected, and you can still work with implicit meaning themes. [source for barriers: Podcast ep. 138]
• Stuck in a struggle; demand for an answer ("Just tell me whether God exists / whether I'm forgiven"). Response: acknowledge the wish for certainty, explain that resolution is not required for relief (as in Winding Road), focus on how the client lives with the question, and offer referral to a trusted religious teacher for doctrinal answers. [source on non-resolution: UCLA]
• Overwhelm during struggle or trauma work (panic, terror, flooding, dissociation; seen in Winding Road members and in Solace for the Soul body and sexuality sessions). Response: slow the pace, return to grounding and stabilisation, and sequence the hardest themes (body, sexuality, abuse in religious settings) after safety and skills are established. Expect a temporary rise in symptoms and tell the client in advance. [source: UCLA; Family Practice News 2005]
• Suicidal thinking (reported among Winding Road participants; greater suicidality has also been found among veterans with high levels of struggle). Response: standard structured risk assessment, safety planning and lethal-means counselling (safe storage and removal). Ask specifically whether spiritual beliefs make the risk higher (e.g., wish to be reunited with the dead, feeling condemned) or lower (e.g., moral objections, community ties), and include protective spiritual resources in the safety plan where the client endorses them. Do not argue theology about suicide. Make sure the client knows where to get help between sessions: in the US, call or text 988 (Suicide and Crisis Lifeline); in the UK and Ireland, Samaritans on 116 123. [source: UCLA for suicidal thoughts in Winding Road; APA Science Brief 2020 for veterans]
• Non-adherence to spiritual homework. Response: check fit. Was the practice the client's choice, does it clash with their tradition, does it stir guilt? Shrink the task, or swap a religious practice for a secular equivalent or the reverse.
• Practice turns punitive or compulsive (scrupulous prayer, ritual checking, self-punishment). Response: assess for OCD/scrupulosity. Use exposure and response prevention, with consent and with clergy input where the client wants it, so that the work respects legitimate practice. Stop using that practice as a coping homework.
• Ruptures about religion or politics. Response: see 4.18. Name the moment, own your part, and explore it. The authors treat these moments as opportunities. [source: Podcast ep. 138]
• Value conflicts between therapist and client (e.g., the client's tradition holds views on sexuality, gender or family that the therapist finds harmful). Response: stay with the client's goals. Do not covertly undermine their faith or collude with harm. Get consultation. Refer if you cannot work without bias. Where safety is at stake, follow safeguarding duties regardless of religious justification.
• Religious or spiritual abuse, including clergy abuse. Response: follow mandatory-reporting and safeguarding duties. Don't push forgiveness or reconciliation (4.14). Validate interpersonal struggle without forcing a choice between faith and community, and offer trauma-focused treatment with SIP elements (4.17) as an adjunct. [source on adjunct framing: Family Practice News 2005]
• Demonic attributions or possible psychosis. Response: assess mental status, perceptual disturbance, cultural norms (is this belief shared by the client's community?), dissociation and trauma. Collaborate with psychiatry where needed. With consent, involve the client's own religious authority on the religious meaning. Never endorse or carry out deliverance or exorcism, and warn against practices that involve restraint, deprivation or violence.
• Spiritual practices that bring up adverse states (anxiety, depersonalisation, re-experiencing trauma during meditation or intense prayer). Response: shorten the practice or anchor it externally (eyes open, movement, grounding). Pause it in clients with active psychosis or unstabilised trauma, and reintroduce it gradually.
• Client wants to stop medication or care on religious grounds. Response: explore the meaning without contempt, give clear information about risks, involve the prescriber, and, with consent, involve clergy (many traditions support medical care). Respect autonomy within safety limits.
• Group-specific difficulties (members of different faiths judging each other, one member proselytising). Response: set ground rules in session 1: speak from your own experience and do not evaluate others' beliefs. Hold the frame firmly, and use the nonsectarian design that made Winding Road workable for a mixed group. [source on mixed group: UCLA]
• Shared-faith over-identification. Response: when you share the client's tradition, guard against assuming shared meanings. Ask anyway. [source on false assumptions of shared meaning: Podcast ep. 138]

Sources

Pages consulted

• Spiritually Integrated Psychotherapy – contents (Guilford)
• Spiritually Integrated Psychotherapy – print/description page (Guilford)
• Working with Spiritual Struggles in Psychotherapy – summary (Guilford)
• Working with Spiritual Struggles in Psychotherapy – print/description page (Guilford)
• Training and manuals for providers – kennethpargament.com
• SIP evaluation studies – kennethpargament.com
• The Winding Road: addressing college students' spiritual struggles (UCLA Spirituality in Higher Education newsletter)
• Papers by Kenneth Pargament – Academia.edu profile
• Spiritualized Therapy Helps Sex Abuse Survivors – Family Practice News, 1 April 2005
• Episode 138: Working with Spiritual Struggles in Psychotherapy – Psychiatry & Psychotherapy Podcast (Pargament & Exline)
• Virtual Grand Rounds: Spiritually Integrated Psychotherapy (Silver Hill Hospital, 2025) (learning objectives only)
• Pargament, K. I., & Exline, J. J. Religious and spiritual struggles. APA Science Brief, 1 November 2020

Books and papers cited (paper details as listed on kennethpargament.com; chapter-level detail of the books [uncertain])

• Pargament, K. I. (2007). Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred. Guilford Press.
• Pargament, K. I., & Exline, J. J. (2021). Working with Spiritual Struggles in Psychotherapy: From Research to Practice. Guilford Press.
• Murray-Swank, N. A., & Pargament, K. I. (2005). God, where are you? Evaluating a spiritually-integrated intervention for sexual abuse. Mental Health, Religion & Culture, 8, 191–204.
• Rye, M. S., Pargament, K. I., Wei, P., Yingling, D. W., Shogren, K. A., & Ito, M. (2005). Can group interventions facilitate forgiveness of an ex-spouse? A randomized clinical trial. Journal of Consulting and Clinical Psychology, 73, 880–892.
• Wachholtz, A. B., & Pargament, K. I. (2008). Migraines and meditation: Does spirituality matter? Journal of Behavioral Medicine, 31, 351–366.
• Rosmarin, D. H., Pargament, K. I., Pirutinsky, S., & Mahoney, A. (2010). A randomized controlled evaluation of a spiritually integrated treatment for subclinical anxiety in the Jewish community, delivered via the Internet. Journal of Anxiety Disorders, 24, 799–808.
• Dworsky, C. K. O., Pargament, K. I., Gibbel, M. R., Krumrei, E. J., Faigin, C. A., Haugan, M. R. G., Desai, K. M., Lauricella, S. K., Lynn, Q., & Warner, H. (2013). Winding Road: Preliminary support for a spiritually integrated intervention addressing college students' spiritual struggles. Research in the Social Scientific Study of Religion, 24, 309–340.
• Ano, G. G., Pargament, K. I., Wong, S., & Pomerleau, J. (2017). From vice to virtue: Evaluating a manualized intervention for moral spiritual struggles. Spirituality in Clinical Practice, 4(2), 129–144.
• Gibbel, M. R., Regueiro, V., & Pargament, K. I. (2019). A spiritually integrated intervention for spiritual struggles among adults with mental illness: Results of an initial evaluation. Spirituality in Clinical Practice, 6(4), 240–255.