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Private Practice Kickstart
with Miranda Palmer, LMFT
& Kelly Higdon, LMFT

Spirituality and Documentation: Action Steps for Integration

Spirituality and Documentation-Thank you to Maelisa Hall for this great guest post.
If you’re a culturally competent counselor then you’ve considered how spirituality impacts treat
ment. That usually inc
ludes two different aspects:
  1. Looking at your client holistically and taking into consideration their preferences and personal beliefs
  2. Examining your own beliefs so you are able to identify potential biases and support your clients in the best way possible

But have you considered what role spirituality plays in your documentation? I believe that including this key component of our humanity is part of a good cultural assessment and ongoing treatment.

Intake Assessment

Now, this topic may not apply to every client in equal ways but is certainly worth asking about during your basic assessment. Having questions ready as part of your intake process can help to facilitate the conversation in a way that is individualized to each client.

Below are some ways to include questions in your intake paperwork:

  • Have a check box or blank space for clients to write in “religious or spiritual orientation.”
  • Consider having a Religion/Spirituality section of your intake assessment with the following questions to start:
    • Do you consider yourself spiritual or religious?
    • How do you express your spirituality?
    • How does your spirituality/religion impact your life?
    • Would you like to include your spirituality in our work together and how so?

Always consider your typical client when creating questions such as these. For example, if you tend to work with people who identify with a particular religion you may substitute the term “spirituality” for “religion” in most of your questions. However, if you mostly work with clients who do not identify as religious then “spirituality” is likely to be a more inclusive term with which your clients will connect.

You will also want to consider your own marketing and identification. If you advertise yourself as a Christian counselor, for example, then you should definitely include questions related to spirituality and religion. Your clients have likely chosen your services based, at least in part, on that interest.

Perhaps you promote other spiritual practices (such as meditation, yoga, astrology, etc.) on your website or in your marketing. Again, if clients are identifying with that including questions related to how it is important to them will help you to start things off on the right foot.


The Spirituality Assessment

Another idea is to do a separate spiritual assessment with clients. Perhaps you have certain clients who prefer to incorporate these principles more than others and use a supplemental form only when it applies.

You can easily create a one page document or series of questions that goes a bit more in depth and allows you to explore how spirituality impacts your client’s mental health and how the two of you can bring this into the therapy room.

The nice thing about this idea is that you can do this whenever the topic comes up… that may be the first session or the 21st session. It all depends on your client’s needs.

Spirituality in Your Notes

While assessment is key, ongoing treatment is where the real work happens. Again, spirituality may be integrated
through all or only certain part of treatment but when it is, you may want to document this important discussion.

Here are some common situations that arise during therapy and relate to spirituality. I would recommend including these topics in notes when discussed during sessions as they typically relate to broader issues and become ongoing topics:

  • Spiritual identity and recent struggles or questioning related to that
  • Struggle of relating to family due to changing religious orientation or expectations
  • Impact of religious orientation on self-worth
  • Identification and interplay of ethnicity and religion
  • Gender roles and religious beliefs
  • Religion and marital discord

Now it’s time to take some action! I challenge you to review your notes.

Do you ever include these topics? Consider your clients. Do these issues sound familiar and come up and if so, are they fairly represented in your case notes? I find these are often a part of conversations but not a part of documentation.

You can also schedule an hour to review your intake form. Consider the questions and ideas presented at the top of the article and examine how they may relate to your clients. Then identify what may benefit your clients by adding to your intake forms.

By simply spending 1-2 hours in some reflection and revision you may invite more in-depth conversations with your clients and connect with them in new ways. Leave a comment below and let us know how it goes for you!

unnamed (3)Maelisa Hall, Psy.D. specializes in teaching therapists how to connect with their paperwork so it’s more simple and more meaningful. The result? Rock solid documentation every therapist can be proud of! Check out her free online Private Practice Paperwork Crash Course, and get tips on improving your documentation today.
Spirituality and Documentation: Action Steps for Integration

 


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APA Reference
Higdon, K. (2019). Spirituality and Documentation: Action Steps for Integration. Psych Central. Retrieved on April 22, 2019, from https://pro.psychcentral.com/kickstart/2016/02/spirituality-and-documentation-action-steps-for-integration-2/