The 1980s witnessed the development of the Multicultural Counseling Competencies (MCC). The primary focus of the MCC was to provide guidance to counselors working with racially and ethnically diverse clients [23,32]. In 1991, the MCC was approved by the Association for Multicultural Counseling and Development (AMCD) as standards for counselors' training and practice [33]. Initially, the MCC focused primarily on racial and ethnic aspects of diversity; religion, spirituality, and other aspects of diversity were added later, and the MCC was updated to be the Multicultural and Social Justice Counseling Competences (MSJCC). However, spirituality and religion, along with other aspects of diversity, continue to be under-represented in the MCC, raising doubt as to whether a multiculturally competent counselor is necessarily spiritually competent [23,27]. The MSJCC, ASERVIC, the American Counseling Association (ACA), and the Society for Sexual, Affectional, Intersex, and Gender Expansive Identities (SAIGE) work closely to provide inclusive competencies for mental health counseling theories, practices, and research [105].

Based on studies validating the positive correlation between religion and health, professional organizations have increased their efforts to infuse spirituality and religion into counseling, training and practice [6,10]. Both the American Psychological Association (APA) and the ACA have formally acknowledged religion in their ethical guidelines as an issue for counselors to consider in their practice [48,49]. Additionally, the APA has authorized a division (36 Society for the Psychology of Religion and Spirituality) specifically for the study of the psychology of spirituality and religion [10].

The ASERVIC competencies continue to serve as a guideline for addressing spiritual and religious issues in counseling and are intended to be used with traditional counseling techniques that are evidence-based and coincide with best practices. The 14 competencies are grouped under six primary categories [6]:

The word spirituality is derived from the Latin root spiritus, which means breath of life [1,55]. Due to the elusive nature of the concept of spirituality, leaders attending the first Summit on Spirituality found it difficult to define. Instead, they chose to describe it as [6]:

Spirit may be defined as the animating life force, represented by such images as breath, wind, vigor, and courage. Spirituality is the drawing out and infusion of spirit in one's life. It is experienced as an active and passive process. Spirituality is also defined as a capacity and tendency that is innate and unique to all persons. This spiritual tendency moves the individual toward knowledge, love, meaning, peace, hope, transcendence, connectedness, compassion, wellness, and wholeness.

Spirituality includes one's capacity for creativity, growth, and the development of a value system. Spirituality encompasses a variety of phenomena, including experiences, beliefs, and practices. Spirituality is approached from a variety of perspectives, including psychospiritual, religious, and transpersonal. While spirituality is usually expressed through culture, it precedes and transcends culture.

The word religion is derived from the Latin word religio, which means a bond between humanity and greater-than-human power [56]. Many people use the terms religion and spirituality interchangeably; however, they are two separate concepts that often overlap [10,39,57]. Spirituality is a personal connection with the universe, whereas religion is an organized community of faith that has a written doctrine and codes that regulate behavior [14]. Although they are two separate concepts, both incorporate a sense of transcendence—a belief in something greater than oneself [58].

Before discussing the various religious and spiritual beliefs and practices, it is important to have an understanding of the concept of "worldview" [61]. Worldview refers to one's total outlook on life. Clients' worldviews are shaped by their culture, religion and/or spirituality, race, ethnicity, sociopolitical factors, age, ability, sexuality, gender expression, family, and other variables. These variables interact to form clients' total worldviews, which influence the way they think, feel, and behave [14,15,27]. Wiggins-Frame writes that, "counselors must be aware that our clients bring to us not only their problems and their pain but also their views of the world molded by culture, religion, and the intersection of the two" [53].

The three major Western religions are Judaism, Christianity, and Islam. All three are monotheistic, meaning their followers believe in one Supreme Being or God who created and sustains the universe. The major Eastern religions include Hinduism, Buddhism, Confucianism, Taoism, and Shintoism. These religions are typically polytheistic (worshiping more than one God) or pantheistic (God is manifested in the forces and laws of the universe). A separate group of religions may be described as atheistic or agnostic [15]. Atheism is the disbelief in the existence of a god or gods; agnosticism holds that the existence of God is unknown and unknowable [27,53,62].

The three major Western religions are Judaism, Christianity, and Islam. All three are monotheistic, meaning their followers believe in one Supreme Being or God who created and sustains the universe. The major Eastern religions include Hinduism, Buddhism, Confucianism, Taoism, and Shintoism. These religions are typically polytheistic (worshiping more than one God) or pantheistic (God is manifested in the forces and laws of the universe). A separate group of religions may be described as atheistic or agnostic [15]. Atheism is the disbelief in the existence of a god or gods; agnosticism holds that the existence of God is unknown and unknowable [27,53,62].

Jewish law focuses on dietary practices, the Sabbath, and annual holidays or festivals. Observing the dietary laws is called keeping kosher. One's home is considered the table of the Lord, and therefore certain animals considered unclean (e.g., pork, shellfish) are not to be eaten. However, animals with split hooves and animals that chew their cud are acceptable. Acceptable animals must be slaughtered correctly, must have the blood drained from them, and must not be served with dairy products. Those who adhere to kosher laws have separate sets of dishes and utensils for preparing and serving meat, dairy products, and Passover meals [53,65].

Christians also believe Jesus is both human and divine or God in human form [65]. As an ongoing source of comfort and guidance, God offered them the Holy Spirit [65,66]. Christians believe God's grace is a gift and that it saves them from evil, sin, and death. Moreover, grace is earned not by doing good deeds or obedience to the law, but through living by the teachings of Jesus Christ [27,65]. The concept of the Trinity is also basic to Christian belief. Although God is perceived as one, God is also expressed in three roles: Father (Creator), Son (Redeemer), and the Holy Spirit (Sustainer) [53,65].

Baptism and the Eucharist or Holy Communion are the primary sacraments celebrated in most Christian churches [53]. Baptism symbolizes the forgiveness of sins, new life, and initiation into the Christian church. During the baptism, persons are either immersed in water or water is sprinkled or poured over them. Eucharist or Holy Communion is a ritual meal in which bread and wine are taken in remembrance of the body and blood of Jesus that was broken and shed at the cross [27]. Major Christian holidays include Easter (commemorating the death and resurrection of Jesus Christ) and Christmas (celebrating the birth of Jesus).

Islam is the fastest-growing religion in the United States and throughout the world [41]. Members of Islam are called Muslims, and approximately 3.45 million live in the United States [41]. Islam means "to surrender" in Arabic. However, from a religious perspective, Islam means "to surrender to the will of God" [67]. Islam began in Arabia around 570–632 C.E. and was founded by the prophet Muhammad. It is a monotheistic religion whose followers believe there is one God and that Muhammad was his last Prophet. They believe the Qur'an (or Koran) is the literal word of God (or Allah in Arabic) that was revealed to Muhammad and mediated by Gabriel, the angel of revelation [67]. Arabic is the language used in Islamic prayer/liturgy [62]. Major festivals or holidays include Al-Hijra, Milad un Nabi, Ramadan, Eid al-Fitr, Eid al-Adha, Day of Ashura, and Laylatul Qadr.

The Five Pillars are the core beliefs and practices of Islam. The first is the Shahada (profession of faith)—the belief that there is no god but Allah and Muhammad is his messenger [27]. The second pillar is the Salat (ritual prayer). Muslims pray facing Mecca five times every day: at dawn, noon, mid-afternoon, sunset, and evening [53]. The prayers are usually performed on a rug or mat specifically for this purpose. Zakat (almsgiving) is the third pillar of Islam. Muslims are expected to donate a certain portion of their income to community members in need [68]. Sawm (or fasting) is the fourth pillar of Islam. During the daylight hours of Ramadan, healthy adult Muslims are expected to abstain from food, drink, and sexual relations. This is a time of reflecting, renewing faith, and being grateful for everything Allah has given [68]. The fifth pillar of Islam is Hajj (pilgrimage). After 16 years of age, every Muslim in good health and whose finances permit is expected to visit the holy city of Mecca, located in present-day Saudi Arabia.

The Four Noble Truths and the Eightfold Path are essential to understanding Buddhism. The Four Noble Truths have been identified as the first teaching given by Buddha. They are considered one of the most important teachings in Buddhism because they instruct followers on how to end suffering [27,62]. Within the Four Noble Truths is found the Eightfold Path. The Four Noble Truths are [62]:

Shintoism began during prehistoric times on the Japanese islands [79]. Today, Shinto is the religion of Japan, and it has approximately 112 million followers; more than 75% of them follow Buddhism as well [79]. Like Taoism, Shinto has no founder or central figure. It teaches that all things in the world are imbued with a spirit (kami). Therefore, Shinto followers revere nature in all forms [78].

A counselor has the potential to intentionally or unintentionally influence a client toward his/her own worldview [27]. Therefore, counselors should be mindful and monitor how their values and beliefs might influence the interventions they use in their professional work. If counselors have clarity regarding their values and beliefs, they are less likely to lead their clients toward adopting their values and beliefs. The counselor's task is to provide a nonjudgmental and accepting environment for clients to discuss their religious and spiritual concerns. Counseling does not entail making decisions for the client, teaching them "appropriate" values, or steering clients toward accepting the counselor's perspective [27]. Instead, counselors should keep in mind that the client is responsible for determining which values to maintain, discard, replace, or modify [27].

McLennan et al. suggest counselors engage in self-exploration to determine how their religious and spiritual values and beliefs might impact the therapeutic process [87]. Not doing so could lead to negative consequences, such as [27]:

The first and most basic limitation for counselors to consider is whether they can work with clients around spiritual or religious concerns [27]. Some counselors may have their own spiritual concerns due to past experiences and may not feel comfortable discussing religious and spiritual issues with clients [27]. Acknowledging any reluctance to address spiritual and/or religious matters is an important step toward understanding one's limitations. Upon noting one's reluctance, growth in comfort and competence is necessary [27].

The second professional limitation to consider involves the assessment of clients' spectrum of spiritual concerns. A client's presenting concern is often related to his/her current spiritual beliefs and practices (e.g. "How can God allow me to feel so much pain in this situation?"). Other times, presenting concerns are influenced by the client's spiritual beliefs and practice (e.g., "Should I have a sexual relationship with my girlfriend?") [27].

A third limitation is clients being challenged by their own or others' beliefs and practices [27]. Some clients may be having a crisis of faith, have experienced spiritual abuse, or may feel unable to achieve the standards of their religion.

Lastly, it is important for counselors to avoid crossing professional boundaries and adopting the role of a religious leader; doing so would interfere with the therapeutic process [27]. Counselors who are self-aware know when to refer a client to spiritual and/or religious community resources. For example, if a client's concern is related to religious doctrine or scripture, a referral to a clergy might be necessary. Counselors should also be familiar with their referral sources and with the spiritual resources in the community [27].

Spiritual development has been identified as a normal part of the human development process [27]. To become competent in this area, counselors should be familiar with the various models of spiritual development. Spiritual development models differ in form and usually imply a process of growth over time [27,53]. Some theorists view spiritual development as a continual process, instead of a process of moving from one stage to another [88]. However, most spiritual development models are linear and hierarchical, and each stage of development builds on the previous stage [53]. Usually, individuals must complete each stage successfully before moving to the next stage. Further, each stage is designed to follow a chronologic sequence based on age or life stage [53]. These models are useful because they assist counselors in understanding how clients integrate faith into their lives [53]. Furthermore, they give counselors an idea as to where clients are in their spiritual and religious development [53]. This section will discuss a variety of models of spiritual development, including Allport's theory of faith development, Fowler's Stages of Faith, Oser and Gmunder's religious judgment model, Genia's faith development model, and Washburn's theory of transpersonal development.

Stage 2 is satisfying rationalism. This usually begins during the turbulence of adolescence. During this stage, individuals start questioning what they have been taught about religion and spirituality and begin to seek an identity separate from their parents [90]. Many individuals enter this stage in their teenage years, becoming rebellious and starting to reject parental values, including religious and/or spiritual ones [89].

Stage 1 of Fowler's model is referred to as primal faith, and it occurs during infancy and before language development. At this stage, children experience faith as a connection between themselves and their caregivers. Infants are learning to trust their caregivers to meet their needs. If their needs are met, they gain hope, love, courage, and trust; however, unfulfilled needs lead to narcissism or isolation [91].

Washburn's theory of psychospiritual development is based on psychoanalytic theory and transpersonal psychology [27,94]. According to Washburn, the primary aim of human development is spiritual fulfillment [27]. He envisioned spiritual fulfillment resulting from the interplay between the ego (personal aspect) and the Dynamic Ground (spiritual aspect), which is a lifelong process. During this interplay, the ego functions receptively (moves closer to the Ground) or actively (moves away from the Ground) [27]. The interplay between the ego and the Dynamic Ground continues throughout the developmental process as both evolve through the three stages [27].

The ability to intensify clients' exploration of their spirituality relies on the counselor's communication skills [27]. Spirituality is very personal, and deeper exploration of a client's spirituality can be very therapeutic, especially when counselors express genuine interest in client beliefs [27]. Effective communication regarding spiritual and religious issues involves avoiding four common barriers to miscommunication. The first type of miscommunication occurs when counselors do not accurately convey spiritual or religious content discussed in the session [27]. Second, counselors may also be inconsistent or incongruent with their communications. Third, counselors may struggle with limitations and complexities inherent in the language clients use when discussing their religious and/or spiritual beliefs [27]. Finally, counselors may inappropriately express judgment or disapproval of clients' beliefs and values [27]. Avoiding these four types of miscommunication will lead to a more trusting therapeutic relationship. Clients may feel discouraged from discussing spiritual or religious issues when counselors are not consistent in their communication of being open to exploring client spirituality [27]. Openness and consistency should start at the beginning of the counseling session, preferably during the intake process [53].

Another key element of effective communication is matching the client's language or terminology [27]. For example, if a client uses Allah in reference to God, counselors should do the same rather than using another comparable term, such as Higher Power [27]. Using words outside of the client's frame of reference during counseling can damage the therapeutic relationship [27]. Often, clients will not feel comfortable initiating discussion about spiritual concerns in counseling and will use indirect messages of spirituality instead [27]. Therefore, counselors should listen for spiritual themes, which can take many forms. These themes may be centered around ideas of the sacred, a belief in a just universe, death or loss, and/or finding meaning and purpose [27].

Both spiritual assessments and informed consents are needed prior to incorporating spirituality or religion into therapy. A primary function of a spiritual assessment is to determine whether religious or spiritual issues are germane to the client's presenting problem or to ascertain if the presenting problem is spiritual or religious in nature [62]. There are a variety of purposes to assess the client's religious and spiritual perspective, including to [15]:

The intake process and the clinical interview are usually the first steps in the spiritual assessment process [53]. Both the intake and the clinical interview give counselors the opportunity to learn about the client, the client's concerns, and the client's worldview (including spiritual and religious perspectives) [27,53]. Information gathered during the intake process usually includes demographic information, a description of the presenting problem, current problem-solving techniques, medical history, mental health status, and family background [53]. When conducting an assessment of the client's spiritual and/or religious perspective, certain factors should be considered, such as family religious and/or spiritual history, its impact on the client's upbringing, and the client's past experiences with spiritual or religious issues [62,95].

When making a diagnosis, it is important to remember that positive or healthy spiritual beliefs may enhance well-being while negative or unhealthy spiritual beliefs can contribute to the problem by diminishing hope and instilling fear. When working in the realm of spirituality and mental health, the risk of misdiagnosis increases [27]. Counselors who are spiritually and religiously oriented tend to be more inclined to underdiagnose clients, while counselors who adhere to a biomedical model may overlook spiritual influences and/or diagnose them as treatable disorders [27]. A counselor who lacks understanding of transformative processes may pathologize spiritual experiences rather than contextualizing them as spiritual and/or religious [27]. Conversely, counselors who shy away from diagnosing clients may be more likely to label a diagnosable disorder as a spiritual experience [27]. Essentially, it is vital for counselors to be able to discern diagnosable mental disorders/symptoms and spiritual experiences [27].

When making a diagnosis, it is important to remember that positive or healthy spiritual beliefs may enhance well-being while negative or unhealthy spiritual beliefs can contribute to the problem by diminishing hope and instilling fear. When working in the realm of spirituality and mental health, the risk of misdiagnosis increases [27]. Counselors who are spiritually and religiously oriented tend to be more inclined to underdiagnose clients, while counselors who adhere to a biomedical model may overlook spiritual influences and/or diagnose them as treatable disorders [27]. A counselor who lacks understanding of transformative processes may pathologize spiritual experiences rather than contextualizing them as spiritual and/or religious [27]. Conversely, counselors who shy away from diagnosing clients may be more likely to label a diagnosable disorder as a spiritual experience [27]. Essentially, it is vital for counselors to be able to discern diagnosable mental disorders/symptoms and spiritual experiences [27].

Counseling goals should be clear, observable, measurable, and attainable so sessions do not appear aimless. Moreover, these goals should be consistent with the client's belief system [27]. Clients' participation in goal setting is very important, and goal setting for spiritual and religious matters should come primarily from the client. There are three types of outcome goal settings to keep in mind throughout the counseling process: collaborative goals, counselor process goals, and spiritual and religious goals [27]. Collaborative goals are developed by the client and the counselor together [27]. Counselor process goals are developed by the counselor for their work with clients, the therapeutic relationship, and the process [27]. Usually, these goals are not shared directly with the client. Spiritual and religious goals are developed for the client's spiritual and/or religious growth. These goals tend to be less specific or behavioral, which makes outcomes difficult to measure [27].