A total of 1,327 people visited the survey landing page. Thirteen participants did not proceed beyond this page, and another 49 did not proceed beyond the online consent form, which revealed the topic of the survey. An additional 34 did not complete the survey, and 3 completed the survey, but reported not being licensed or certified mental health professionals, leaving a total of 1,241 participants included in the sample.
Sampling bias
Upon preparing the data for analysis, we recognized that nearly half of the respondents who had taken degree courses or continuing education workshops in R/S had attended more than three courses (n = 144, 41.5%) or continuing education workshops (n = 265, 50.8%). This is an unusually high level of training in R/S when compared with previous data on prevalence of training among mental health professionals [27, 29]. While this could reflect recent increases in R/S training across mental health professions, sampling bias is more likely. Despite our efforts to reduce biased sampling by masking the topic of the survey and using recruitment sources without an R/S focus, the recruited sample appeared to include a higher number than usual number of mental health professionals with a strong interest in R/S.
Since our intention was to gain input from a more generalized sample of mental health professionals, to be conservative and avoid results and interpretations with a positive bias toward R/S, we elected to remove data from respondents who had attended more than 3 courses in R/S (n = 86), as well as participants who were pastoral counselors (n = 79). Finally, data from 19 participants who were not mental health providers was deleted. In total, 894 participants were included in the analyses.
Demographic characteristics
The majority of participants were women (78.0%), aged either between 45 and 54 years (25.0%) or between 55 and 64 years (26.4%). Most respondents were White (79.6%), married (61.0%), and lived in suburban areas (61.3%). Less than half of respondents made over $100,000 annually (43.7%) (See all demographic information in Additional File 2).
Professional background and training
The majority of respondents had a master’s degree (67.6%), followed by those with a doctoral degree (31.4%). 28% were licensed social workers, 21.9% were licensed professional counselors, 19.1% were licensed marriage family therapists, 14.4% were licensed clinical psychologists, 4.4% were psychiatrists, 2.0% were chemical dependency counselors, and 0.8% were psychiatric mental health nurses. Most respondents worked either in solo private practice (40.2%) or at a non-profit agency (20.6%). Professionals reported a mean of 19.29 (SD = 11.17) years in clinical practice (See all educational and professional background in Additional File 3).
Spiritual and religious background, beliefs and practices
Nearly half the sample (41.1%) was Christian, while 35.1% considered themselves spiritual but not religious. 63.7% reported they were either not religious or only slightly religious, whilst 48.4% described themselves as very spiritual.Most participants (55.9%) considered their R/S to be liberal, 17% moderate, and 17.6% conservative. Finally, high levels of daily spiritual experiences were observed, including 71.7% experiencing the presence of the divine (71.7%), R/S lying behind their approach to life (71.7%), and trying to carry R/S into all areas of life (65.4%) (See all R/S backgrounds, beliefs and practices in Additional File 4).
Hypothesis testing
H1 views on training in R/S competencies
It was hypothesized that 70% of mental health professionals would agree that licensed and practicing clinicians should receive training in R/S competencies. Across all competencies, 89.1% of the respondents agreed somewhat or very much and 10.9% agreed a little bit or not at all. Depending on the specific competency, between 81.2% and 96.0% of all participants endorsed that mental health professionals should receive explicit training somewhat or very much, and over 50% of participants endorsed “very much” for all competencies. Therefore, H1 was supported.
Mental health professionals displayed the greatest levels of agreement with the training on demonstrating empathy, respect, and appreciation to R/S diverse clients (96.0%), conducting empathic and effective psychotherapy with R/S diverse clients (94.9%) and cultivating awareness of clinicians’ R/S influence on psychological processes (94.8%). The lowest levels of endorsement were observed in the training on identifying and addressing R/S problems in clinical practice (81.2%), helping clients explore and access R/S strengths and resources (83.0%) and differentiating between spirituality and religion (84.8%) (See all descriptive analysis in Additional File 5).
H2 amount of explicit R/S competency training
It was hypothesized that 50% of mental health professionals would report receiving little to no explicit training in religious and spiritual competencies. Nearly half of the respondentsindicated that during their professional degree program they had not received anyor not very much training in addressing R/S in practice. (Table 1).
Across all R/S competencies, 69.4% reported no training at all or a little bit of training. Consequently, H2 was supported. The least training was observed in identifying of potentially harmful R/S practice, beliefs, experiences; being aware of R/S resources and practices supporting mental health; and identifying and addressing R/S problems in clinical practice. The highest levels of training (nearly 50% reported some training) were reported for awareness of clinicians’ R/S influencing their views on psychological processes, conducting empathic and effective psychotherapy with R/S diverse clients, and understanding of R/S importance to human diversity (See descriptive analysis on explicit R/S competency traning in Additional File 6).
H3 self-rated R/S competence
Hypothesis 3
postulated that 50% of mental health professionals would rate themselves as mostly or completely competent in R/S domains, despite a general lack of training. Half of the respondents (49.9%) rated themselves as having quite a bit or a lot of proficiency in attending or integrating clients’ or patients’ R/S backgrounds, beliefs, and practices in mental health care. Across all R/S competencies, depending on the particular competency, 57.8% indicated that they were able to display them very much or completely. Therefore, H3 was supported.
The least proficiency in self-rated R/S competencies were awareness of R/S legal and ethical issues related to clinical practice (37.0%), identification of potentially harmful R/S practice, beliefs, experiences (44.3%), and identification and address of R/S problems in clinical practice (42.9%). The highest self-rated R/S competences were awareness of clinicians’ R/S influence on psychological processes (74.8%), empathy, respect, and appreciation to R/S diverse clients (75.1%) and understanding of R/S importance to human diversity (73.7%) (See descriptive analysis on self-rated R/S competence in Additional Files 7).
H4 barriers to R/S competent mental health care
It was hypothesized that mental health professionals would report at least one barrier to engaging in R/S competent mental health care. In total, nearly two-thirds (65.2%) of respondents reported that nothing makes it less likely that they would attend to R/S in clinical practice. In the remaining 34.8% who did perceive at least one barrier, 11.1% did not have enough time, 8.9% felt they did not have enough training in it, 6.7% stated that their institution/setting does not support it, 5.9% thought their clients would not appreciate it, 2.3% felt personally uncomfortable doing so, 1.6% thought it was not important, 1.3% thought R/S issues should not be discussed in clinical work, and 8.9% cited other barriers. Respondents who chose the other option mostly reported that their engagement would depend on the particular client since R/S issues are seen as a sensitive topic that should be brought up by the client first or once a therapeutic alliance has been established. Consequently, H4 was not supported.
H5 R/S training as a positive predictor of self-rated R/S proficiency
A simple linear regression analysis was conducted to evaluate if R/S training was a statistically significant positive predictor of R/S self-rated proficiency. A total score was computed for the number of R/S classes and continuing education/workshops attended. Self-rated proficiency was rated with a single item (“Please rate how much proficiency you have in attending to or integrating your clients’ or patients’ R/S backgrounds, beliefs and practices in mental health care”) with higher scores indicating greater self-rated proficiency.
The analysis indicated a model that was statistically significant [F(1, 325) = 4.61, p = .032], but accounted for only 1.1% of the variance in self-rated proficiency (R2 = 0.014, R2adj. = 0.011). R/S training was a also statistically significant positive predictor of perceived competency (β = 0.12 t = 2.15, p = .032), suggesting that individuals who attended a greater number of R/S classes and continuing education/workshops were more likely to evaluate themselves as more proficient in R/S clinical integration. Therefore, H5 was supported.
H6 age and R/S orientation as positive predictors of importance of R/S training
A multiple linear regression was performed to examine if age and R/S orientation were statistically significant positive predictors of importance of R/S training. A total mean score to assess importance of R/S training across all R/S competencies was calculated, with higher scores being indicative of greater importance. A statistically significant model was identified that accounted for 6.9% of the variance in importance of R/S training.Age was a statistically significant negative predictor, whereas spiritual orientation was a statistically significant positive predictor, suggesting that younger and more spiritual individuals were more likely to consider R/S training more important. Religious orientation was not a statistically significant predictor (Table 2). Consequently, H6 was partially supported.
Secondary analyses
Differences between professional disciplines
ANOVAs were conducted to assess whether there were differences across mental health disciplines (psychiatrists, psychologists, MFT, LCSW, professional counselors, and pastoral counselors) in their rating of importance of R/S competencies in training, self-rated R/S competence, and having received training in R/S competence between. There were no significant differences between disciplines, with the exception of pastoral counselors reporting having received more training in R/S competencies than other professions F(5,661) = 3.67,p = .003.
R/S inquiry and engagement
On average, mental health professionals reported verbally inquiring about religion or spirituality in the course of assessment or treatment with over 60% of their clients. Just over half of respondentsinquired with three-quarters or more of their clients/patients, about a fifth inquired with almost all of their clients/patients, and almost a third inquired with less than about a third of clients/patients. Regarding actual engagement in other clinical practices addressing R/S, nearly two-thirds of mental health professionals reported engaging very often or often in helping clients consider ways their R/S support systems may be helpful, just over half reported both involving clients in deciding about R/S treatment integration and helping clients consider R/S meaning and purpose of current life situations.(Table 3).
Perceived importance of R/S training and sociodemographic characteristics
A multiple linear regression was performed to investigate if gender, age, R/S training, R/S orientation, frequency of attendance at religious services (ORA), frequency of private religious activities (NORA), intrinsic religiosity (IR), and R/S upbringing would be statistically significant predictors of importance of R/S training. A total score was computed for the number of R/S classes and continuing education/workshops attended. Regarding IR, a mean score was calculated for the three items included in the subscale, with higher scores indicating greater IR. Finally, a mean score was calculated for the 15 items training importance in specific R/S competencies, with higher scores suggesting greater perceived importance.
The analysis indicated a statistically significant model that accounted for 9.9% of the variance in importance of R/S training. Gender, R/S training, and spiritual orientation were statistically significant positive predictors, suggesting that women and professionals with greater R/S training and spiritual orientation were more likely to perceive R/S training as more important. The rest of the predictors were notstatistically significant (Table 4).
