A CALL TO SPIRITUAL HUMILITY: AN EXPLORATION OF SPIRITUALITY, THE US HEALTHCARE SYSTEM AND BEHAVIORAL HEALTH PROVIDERS by Taylor P Young May, 2024 Director of Dissertation: Damon Rappleyea, Ph.D. Major Department: Human Development and Family Science ABSTRACT Though spirituality has become a more prominent feature in holistic healthcare it is still overlooked in US healthcare systems and behavioral health providers (BHP). The impact of spiritual inclusion in healthcare has been demonstrated to have a beneficial impact on medical and psychological treatment. Researchers and healthcare practitioners must continue to explore how to acknowledge spirituality and access their associated benefits for the patients they work with. The purpose of these studies is to shed light on how BHPs and their training can play a pivotal role in acknowledging spirituality within holistic healthcare in the US healthcare system. The 5 chapters in this dissertation, include a/an: (a) Introduction to spirituality and its benefits within the US healthcare system through Peek’s 3 world view, (b) systematic review of spirituality training interventions for BHPs, (c) methodology chapter describing the original study, (d) original research study that reports the results from a mixed methods survey exploring BHP past spirituality training and how it influences BHP spiritual integration scores, and (e) conclusion chapter. ii iii A CALL TO SPIRITUAL HUMILITY: AN EXPLORATION OF SPIRITUALITY, THE US HEALTHCARE SYSTEM AND BEHAVIORAL HEALTH PROVIDERS A Dissertation Presented to The Faculty of the Department of Human Development and Family Science East Carolina University TITLE PAGE In Partial Requirements for the Degree Doctor of Philosophy for Medical Family Therapy by Taylor P. Young May, 2024 Director of Dissertation: Damon Rappleyea, PhD, LMFT Dissertation Committee Members: Jake Jensen, PhD, LMFT Natalia Sira, PhD Heather Quagliana, PhD COPYRIGHT ©Taylor P Young, 2024 ii ACKNOWLEDGMENTS I would like to recognize those in my life who have allowed me to explore and experience the world throughout my journey as a PhD candidate, therapist, and human. I would first like to thank Jesus Christ and my faith in him. Through this journey I have been able to rediscover my own relationship with Him and allow his presence to be ever present in my care for my clients in an ethical, equitable and appropriate manner. It was through this rediscovery that I found my own curiosity about my clients/patients own spirituality and aid them in finding their purpose and meaning in life through their own beliefs. I would also like to thank my parents who continuously support me with their love, openness, and care even in disagreements. Dan and Jill Young, you created a parenting environment that allowed me to explore and find my own way in many aspects and I am grateful for this. I would like to acknowledge my dissertation committee Drs; Damon Rappleyea, Jake Jensen, Natalia Sira, and Heather Quagliana. A special thank you to both Dr. Rappleyea and Dr. Quagliana. Damon, thank you for your guidance and support as my chair in this process and thank you for the excitement you ignited in me for this topic. Heather, thank you for your continued support that has spanned the past eight years. You have been my biggest supporter for quite some time, and I am looking forward to how our relationship evolves. Lastly, I would like to thank my late friend who was a part of the LGBTQIA community and passed away in spring, 2023 of cancer. Lorenzo, thank you for being vulnerable in your own search of spirituality in our conversations and I am sorry that your search was never fulfilled. iii TABLE OF CONTENTS TITLE PAGE ................................................................................................................................. iii COPYRIGHT ................................................................................................................................... i ACKNOWLEDGMENTS .............................................................................................................. ii LIST OF TABLES ....................................................................................................................... viii LIST OF FIGURES ....................................................................................................................... ix PREFACE ....................................................................................................................................... x Role of the Researcher ........................................................................................................................................xi My Why ..............................................................................................................................................................xi Conclusion ....................................................................................................................................................... xiii CHAPTER 1: THE CURRENT STATE OF SPIRITUALITY: A FOUR WORLD VIEW .......... 1 Clinical ..................................................................................................................................................... 3 Financial ................................................................................................................................................... 5 Operational ............................................................................................................................................... 8 Training .................................................................................................................................................... 9 Purpose/Design ....................................................................................................................................... 10 Conclusion .............................................................................................................................................. 12 REFERENCES ....................................................................................................................................... 13 CHAPTER 2: EVERYWHERE BUT NOWHERE: A SYSTEMATIC REVIEW ON SPIRITUAL TRAINING INTERVENTIONS FOR BEHAVORIAL HEALTH PROVIDERS . 18 iv Introduction ............................................................................................................................................ 18 Theoretical Underpinnings ................................................................................................................................. 20 Literature Review ................................................................................................................................... 22 Spirituality and Religion .................................................................................................................................... 22 Spirituality and BHPs ......................................................................................................................................... 23 The Missing S .................................................................................................................................................... 25 Aim and Research Questions ............................................................................................................................. 26 Methods .................................................................................................................................................. 26 Search Strategy .................................................................................................................................................. 26 Inclusion/Exclusion Criteria ............................................................................................................................... 27 Data extraction ................................................................................................................................................... 27 Results .................................................................................................................................................... 29 Setting ................................................................................................................................................................ 29 Profession ........................................................................................................................................................... 29 Intervention Type ............................................................................................................................................... 29 Differentiates Spirituality from Religion ........................................................................................................... 30 Themes ............................................................................................................................................................... 31 Discussion ............................................................................................................................................... 36 A Clinical Starting Point: Spiritual Generalist ................................................................................................... 38 A Proposed Framework: Spiritual Humility ...................................................................................................... 39 Spiritual Humility and BPSS ............................................................................................................................. 42 Spiritual Humility and How it Fits ..................................................................................................................... 43 Limitations .............................................................................................................................................. 44 Conclusion .............................................................................................................................................. 45 v REFERENCES ....................................................................................................................................... 47 Figure 1. ............................................................................................................................................................. 59 Figure 2. ............................................................................................................................................................. 60 Table 1. .............................................................................................................................................................. 61 Table 2 ............................................................................................................................................................... 62 Table 3. .............................................................................................................................................................. 65 CHAPTER 3: METHOD .............................................................................................................. 77 Filling the Gap ........................................................................................................................................ 77 Theoretical Foundation ........................................................................................................................... 78 Biopsychosocial-Spiritual BPSS ........................................................................................................................ 78 Research Questions and Hypotheses .................................................................................................................. 79 Methodology ........................................................................................................................................... 80 Design ................................................................................................................................................................ 80 Participant Recruitment ...................................................................................................................................... 81 Sample................................................................................................................................................................ 82 Measures ............................................................................................................................................................ 82 Procedures .......................................................................................................................................................... 87 Quantitative Data Analysis ................................................................................................................................ 87 Qualitative Analysis ........................................................................................................................................... 88 Conclusion .............................................................................................................................................. 88 REFERENCES ....................................................................................................................................... 90 CHAPTER 4: MOVING AWAY FROM THE R/S PHENOMENON: AN EXPLORATION OF SPIRITUALITY AND BEHAVIORAL HEALTH PROVIDER TRAINING ............................ 91 vi Introduction ............................................................................................................................................ 91 Theoretical Foundation ........................................................................................................................... 93 Methods .................................................................................................................................................. 94 Design ................................................................................................................................................................ 95 Measures ............................................................................................................................................................ 97 Results. ................................................................................................................................................... 99 Descriptives ........................................................................................................................................................ 99 Quantitative ........................................................................................................................................................ 99 Qualitative ........................................................................................................................................................ 101 Discussion ............................................................................................................................................. 103 The Shift ........................................................................................................................................................... 103 The More You Do the More you Become ........................................................................................................ 104 Who, What, When, Where, Why and How ...................................................................................................... 106 Limitations ............................................................................................................................................ 111 Conclusion ............................................................................................................................................ 112 REFERENCES ........................................................................................................................... 113 Table 1. ............................................................................................................................................................ 118 Table 2 ............................................................................................................................................................. 121 Table 3. ............................................................................................................................................................ 121 Table 4. ............................................................................................................................................................ 122 Table 5. ............................................................................................................................................................ 123 Table 6. ............................................................................................................................................................ 124 vii CHAPTER 5: A CALL TO SPIRITUAL HUMILITY: AN EXPLORATION OF SPIRITUALITY, THE HEALTHCARE SYSTEM AND BEHAVIORAL HEALTH PROVIDERS; CONCLUSION .................................................................................................. 127 Dissertation Review .............................................................................................................................. 127 Contributions to Medical Family Therapy ........................................................................................... 130 Contributions to Spirituality Research.................................................................................................. 131 A Matter of Health ........................................................................................................................................... 132 A Matter of Diversity ....................................................................................................................................... 132 Recommendations ................................................................................................................................ 133 Future Research .................................................................................................................................... 134 Conclusion ............................................................................................................................................ 135 REFERENCES ........................................................................................................................... 136 APPENDIX A: IRB APPROVAL .............................................................................................. 137 APPENDIX B: RESEARCH FLYER ........................................................................................ 139 APPENDIX C: SURVEY ........................................................................................................... 140 APPENDIX D. INCENTIVE...................................................................................................... 150 viii LIST OF TABLES CHAPTER 2 1. PICO Systematic Review Exclusion and Inclusion Criteria………………………….61 2. Characteristics of Spiritual Training Interventions…………………………………...62 3. Spiritual Training Interventions………………………………………………………65 CHAPTER 4 1. Descriptive statistics of spiritual integration of BHPs…..............................................121 2. Spiritual training characteristics effect on Spiritual Integration scores………………124 3. Demographics, experience, and training Effect on spiritual integration scores………124 4. Training characteristics & BHP professions (ANOVA)……………………………...125 5. Score differences (T-Test)…………………………………………………………….126 6. Themes and subthemes related to BHPs opinions on spirituality training……………127 ix LIST OF FIGURES CHAPTER 2 1. PRISMA Systematic Review Search Strategy………………………………………..59 2. Spiritual Humility Framework………………………………………………………..60 x PREFACE “There is nothing in this world, I venture to say, that would so effectively help one to survive even the worst conditions as the knowledge that there is meaning in one's life” (Frankl, 2006, p 109). The desire to research spirituality stemmed from my interactions with Viktor Frankl’s take on the concept and his view on logos (i.e., “the search for meaning”). In his model Frankl created a healing process that connects to my existential nature and points towards a deeper sense of health that few venture towards. I decided to partake in that venture and aim to increase awareness of what meaning and purpose can bring to Biopsychosocial-spiritual (BPSS) health and the US healthcare system. During my marriage and family therapy (MFT) master’s program I was employed at a mental health hospital. Through this experience I interacted with numerous individuals that were repeat patients for multiple psychological struggles. Even though their medications would help there was still something missing that kept them from realizing their full potential in attaining a healthy and full life. In my conversations with these patients, I saw that a significant part of what was missing was spirituality and its connection to meaning, purpose and hope. I saw a connection to a diverse aspect of spirituality that can aid a diverse range of clients/patients in their search of their BPSS health. This then blossomed into an exploration of spirituality throughout my PhD in Medical Family Therapy. I realized that the mission of a MedFT aligned with my desire to fully acknowledge my clients/patients BPSS health and wanted to add to the acknowledgment of spirituality specifically. This venture connected with my own spiritual journey and with my desire to see something more in my own care as a therapist, MFT, MedFT and as a human helping other humans. xi Role of the Researcher Throughout my time as a doctoral student, I realized that diversity and humility are important parts of ethical and equitable care and this applies to spiritual care as well. These aspects should always be at the forefront of my research and my care as a responsible healthcare provider in the US healthcare system. To do this successfully I need to be daily reminded of my own biases as a therapist who values spirituality within their care. The following are some of those biases/belief’s that I need to be aware of, especially in lieu of my focus for my dissertation. These include my own social locations (i.e., white, cis gender, heterosexual, man, educated, middle class, English speaking, Christian, and American citizen) and my views on team-based care (integrated care and the incorporation of behavioral health as equitable and ethical). It is important for me to acknowledge that these beliefs and biases could influence my research on spirituality and with other behavioral health providers within the US healthcare system. The ongoing need for reflexivity and self-reflection is central as I navigate this venture of research. I also must acknowledge the expansive nature of spirituality and how difficult it is to research. It is my privilege and honor to stand on the shoulders of those who have prioritized spirituality in their research and paved the way for this dissertation. My Why For the past thirty years I have personally gone through a journey that has been difficult, enlightening, and purposeful. In this journey I have concluded that my own spiritual search for meaning and purpose is just as important as my clients/patients. It is through this search that I have encountered those who are also on a journey. Through these encounters I discovered aspects of spirituality that were foreign to my own personal experiences. Individuals who were xii looking for purpose and meaning through their own cultures, beliefs and experiences impacted my journey in a profound way. These encounters looked like, discussions with my patients as a certified nursing assistant, talks with my friends who possessed different social locations and interventions with my clients as a therapist. I was able to discuss aspects such as end of life concerns, purpose talks, and different belief’s than that my own. Even though, many with my background would see these encounters as a threat to their belief’s I saw them as enriching, grounding and exciting. In fact, in these diverse encounters, I found a truth in my own beliefs that I have never seen before. This is my why for this dissertation because my own search for purpose and meaning did so much and I know that my clients/patients search can do the same. Even though this topic has been at the forefront of my mind for quite some time, the event that solidified this as my dissertation topic was my experience with my late friend Lorenzo who was a part of the LGBTQIA+ community and struggled with cancer. In what would become my last discussion with Lorenzo he stated, “I do not know what to believe or where to find my own purpose”. His struggle with spirituality and finding purpose emerged from the marginalization he experienced in his identified social location from community members and his family. Lorenzo passed due to cancer a week later and I promised myself that I would work as hard as a I can to aid people in their spiritual search and avoid the “I do not know” statements that occasionally emerge in our lives. In this promise I see uncertainty in our spiritual searching as a life-giving aspect for purpose and meaning because in the search is possibility, discovery, and freedom. I aim to be the person who walks alongside those in the search and provide a friendly hand in a curious and humble manner. xiii Conclusion This dissertation explores the acknowledgment of spirituality in context of the US healthcare system and how BHPs can play their part. The aim of this dissertation is to heighten awareness of the benefits of acknowledging spirituality and truly providing holistic healthcare that addresses the diverse spiritual needs of our clients/patients. It aims to pave the way for BPSS health to be fully addressed and create a more equitable healthcare system. CHAPTER 1: THE CURRENT STATE OF SPIRITUALITY: A FOUR WORLD VIEW Spirituality is a concept that is often misunderstood in the US healthcare system (Balboni et al., 2022; de Brito Sena et al., 2021; & Koenig, 2008). This is due to its ever-expanding nature and its lack of operationalization within research (Koenig, 2008; & Koenig, 2012). However, Koenig (2008) argues for an operational version of spirituality within clinical care. He labels this the modern clinical version of spirituality. According to this version spirituality is an umbrella term that encompasses other terms such as religion, hope, connection, meaning, secularism, etc. This is contrary to historical spirituality which is synonymous with religion. Also, according to this modern version, spirituality is a universal part of humanity and of every person’s healthcare. Meaning that spirituality can be an important part of life for all individuals, even those who are not religious, and use labels such as secular, pagan, or atheist. This change in definition creates a more inclusive view of the term but it also puts more stress on healthcare providers to keep up with the ever-changing theoretical and clinical understanding of spirituality. The connection between the universal nature of spirituality and health has been highlighted within the literature for some time (Oman, 2018; Wright et al., 1996). It has also been and still is an important part of holistic healthcare frameworks like biopsychosocial- spiritual (BPSS) health (Engel, 1977 & Wright et al., 1996). However, despite this acknowledgment providers' comfort with the ever-changing term and incorporating it into healthcare is low and at some points ignored (Kusnanto et al., 2018; & Mendenhall et al., 2021). Even providers whose training is more conducive to cultural inclusivity (Kondili et al., 2022) such as Behavioral Health Providers (BHP) ignore spirituality in their treatment plans, interventions, conceptualization, and care (Errington, 2017; & Ferrell et al., 2020). There are a plethora of reasons for this but the most significant is provider comfort when addressing 2 spirituality (Gillilan et al., 2017; Lloreda-Garcia, 2017; Mendenhall et al. 2021; Rosmarin et al., 2021; & Tehranineshat et al., 2019). This creates the dilemma of Spirituality being missed within the BPSS health and within the larger US healthcare system and in turn creates dilemmas such as increased discrimination, decreased access to care, increased unmet needs, worsened mental health, and much more (Azhar et al., 2022; Dein et al., 2012; Kalánková et al., 2021; Martin et al., 2010; & Michlig et al., 2022). Due to this lack of comfort from BHPs the most logical place for a solution is within the training of BHPs; from their academic training, and continuing education units (CEU) to clinical training. However, to create a clear connection between BHP training and successful acknowledgment of spirituality it is important to review the presence of spirituality in all aspects of the US healthcare system. Spirituality in the US Healthcare System. Peek’s (2008) three World View, which also includes a fourth hidden world (training), provides a helpful framework for understanding the landscape of spirituality within the US contemporary healthcare system. According to Peek (2008), the Three World View includes the clinical, operational, financial, and a hidden world of training/educational worlds. While all four worlds are individually important, together they make up what is necessary for a healthcare system to be successful. The clinical world focuses on direct patient care and the relationship between providers and their patients/clients. It also considers the quality of this relationship and the care provided. The operational world includes organizational policies, protocols, and workflow, while including tools like electronic health records (EHR) and patient communication. The communications include referrals, prescriptions, and the tools that aid in the process. The operational world also includes the personnel and staff that make up a healthcare system, which 3 is not limited to providers (Mendenhall et al, 2021). The financial world comprises payments, reimbursements, and billing systems; it interacts with insurance, third-party payers, and the overall allocation of funds necessary for the healthcare system to operate effectively. Lastly, the training/educational world includes enhancing clinical skills, professional and academic training programs or initiatives, and continuing education for providers within healthcare systems. Each world aids in the optimal functioning of the entire healthcare system. It is important to provide an up-to-date status of spirituality within all four worlds. This will increase insight into incorporating spirituality and its health benefits within the US healthcare system and will highlight the most appropriate world to begin. This introduction will provide that status and argue that the training/educational world is the most logical starting point for the improvement of spiritual care which will in turn affect the other three worlds. Clinical Historically spirituality has found its clinical home within, palliative care, hospice, and nursing, and is newly found in other team-based care models like integrated care (de Diego- cordero et al., 2021; Ferrell et al., 2020). Also, spirituality has become more present within clinical care due to world events like the COVID-19 pandemic. Within palliative and hospice care there is a natural progression towards spiritual concepts within conversations of chronic illness and end-of-life. Patients usually wrestle with questions of meaning and purpose (Taylor, 2021); why is this happening to me, how does this affect my family, relationships, and overall life, what is the point of going on with this prognosis, is this a punishment? To address these questions and other spiritual issues palliative- care and hospice utilize care teams to provide holistic treatment to their patients (Wallerstedt et al, 2018) These 4 teams usually include nurses, chaplains, and physicians. They also include a Behavioral Health Provider (BHP) like a social worker. Through the collaboration of these providers, it is the aim to address a patient's whole BPSS health. However, even though spirituality is a natural part of palliative and hospice care providers still struggle with feeling comfortable in addressing it and often ignore it (Taylor, 2021). Within nursing, there is a consensus that patients and families need holistic/spiritual care (Bahramnezhad & Asgari, 2020). Along with palliative and hospice care, nursing has led the way in incorporating spirituality into care but provider voices of uncomfortably in fully acknowledging it within a patient's health are still prevalent. Hawthorne and Gordon (2019) state the following as reasons for these feelings of discomfort; “fear of imposing their beliefs on others, fear of personal spiritual vulnerability, and limited education in the area of spirituality including spiritual assessment” (p. 148). However, due to care guidelines (JHACO, 2022) nurses are expected to at the very least address spiritual concerns within their care by way of assessments and appropriate referrals. This is due to the research displacing how patients utilize spiritual resources to cope with the broad spectrum of healthcare experiences (Hall et al, 2019). There are also numerous correlations between spirituality and better health outcomes (Balboni et al, 2022), and this is strengthened by over 100 systematic reviews on spirituality and health outcomes in the past 25 years (Oman, 2018). Recent world events have also highlighted the importance of spirituality within healthcare, like the COVID-19 Pandemic. Along with other pandemics, COVID-19 creates uncertainty, fear, and disease containment issues, which in turn increases spiritual issues/questions in patients, their families, and healthcare workers (Bahramnezhad & Asgari, 2020). As a threat to everyday health and 5 wellness, COVID-19 created a vacuum of unanswered questions for patients, similar to palliative care patients. These questions and needs were mostly overlooked because of the strain that the epidemic had on the healthcare industry (Ferrell et al, 2020). One common spiritual need that may have been overlooked is the lack of peaceful death options for hospital patients (Bahramnezhad & Asgari, 2020) and the effect that this has on patients' families. This issue came about because of the high risk of transmission, and patients’ families could not say goodbye or perform spiritual rituals pivotal to their grieving process. Spirituality is often unacknowledged and uncared for in other types of tertiary and secondary care, outside of hospice and palliative care (Balboni et al, 2023), and the same can be said for primary care and mental health services (Isaac et al, 2016; & Rosmarin et al, 2021). This starkly contrasts patients' desire for spirituality to be incorporated into their care. For example, the American Medical Association (AMA) found in one study that 41% of patients desire a deeper conversation about spirituality in relation to their healthcare (AMA, 2016). In another study, 66% percent of patients stated that the act of physicians asking about spirituality would increase their trust in them (Ehman et al, 1999). Within the mental health field, about 80% of patients/clients turn to spirituality to cope with their illness, and half desire to talk about spirituality within psychotherapy sessions (Rosmarin et al, 2021). Because of this, it is important to create, improve upon, and implement models of care that aid in addressing spirituality. Financial A probable connection between spirituality, BHPs and the financial world is the benefit of utilizing systems-trained BHPs (Crane & Christenson, 2014). Systemic BHPs like Marriage and Family Therapists (MFT), Medical Family Therapists, and Licensed Clinical Social Workers 6 (LCSW) tend to practice through a systemic lens (Mendenhall, 2021). Through a systemic lens, healthcare is provided holistically alongside a biomedical provider; this has been shown to reduce the rates of healthcare services utilized (Crane, 2008). This reduction addresses the issue of “high utilizers,” who are patients/clients that utilize services such as emergency rooms and other hospital-based services (Shemesh et al, 2022). Systemic providers are more likely to include spirituality in their clinical work and address BPSS health with patients, but these providers may not have the adequate training to know how to appropriately do so. Outside of BHPs, there are other providers who interact with spirituality in healthcare such as spiritual specialists who bring financial benefits to the healthcare system. Spiritual specialists such as chaplains have been shown to save the healthcare system money by providing spiritual support to not just patients but also to staff and clinicians (Hall & Powell, 2021). Factors such as burnout and compassion fatigue have been shown to increase medical errors (Patel et al, 2018) which in turn creates more financial burden on the system. Spiritual specialists are primed to provide support to providers by exploring spiritual concepts such as the meaning and purpose of their care (Hall & Powell, 2021; & Koenig 2012). This service can also positively impact the working culture of a healthcare system and can improve staff morale, and retention turnover rates (Hall & Powell, 2021). The downside to this benefit is the increase of what could be labeled as shadow work for spiritual specialists. Shadow work is an unforeseen increase in workload that goes beyond a worker's expected load. Even though staff support is included in most spiritual specialist's job descriptions the workload and what is required to significantly decrease medical errors can be ambiguous. However, this should not dissuade systems from parsing out this financial benefit and utilizing spiritual specialists in an appropriate manner. 7 Utilizing spiritual specialists within healthcare also increases patient satisfaction (Hall & Powell, 2021). Patient satisfaction has long been the factor that predicts the success of healthcare facilities and impacts the rate of reimbursements from insurance (Manzoor et al, 2019). When spiritual issues are adequately addressed during a healthcare visit a patient’s experience is shown to be positively affected (Hall & Powell, 2021), which has a positive relationship with the financial world. Those who receive inadequate spiritual care are shown to have higher care costs and higher utilization of services. For example, Morrison et al. (2008) report a monetary savings of $1696 per patient discharged from the hospital who is receiving spiritual care through palliative services and Hall & Powell (2021) highlight these savings as pivotal to the financial world of a healthcare system. Spiritual specialists have the capability to address spirituality and, in the end, reduce the financial burden on healthcare systems. The issue then becomes the ambiguity of spirituality within the billing of healthcare systems (Hall & Powell, 2021). Due to the separation of church and state spiritual care is not typically reimbursable through a billable healthcare code (Warnock, 2008). There have been recommendations for creating billable codes for spiritual specialists, but these are not financially acknowledged by federal funds (CMS, 2023). This is where the connection between spiritual specialists and systemic BHPs is pivotal. Even though BHPs are not able to bill at the same rates as biomedical providers (Mendenhall et al, 2021), they still possess billable codes acknowledged by most states and specifically by federal funds. Systemic BHPs can provide much-needed spiritual acknowledgment within their billable patient/client visits and provide continuous support by collaborating with spiritual specialists. This could be an answer to the shadow work 8 dilemma of spiritual specialists and create a stronger connection between systemic BHPs, spirituality, and the financial world. Operational Within the operational world, spirituality is mostly relegated to spiritual specialists or team-based care (Baxter et al., 2018). However, team-based care is usually limited to specialty areas like palliative care and care models like integrated care (CFHA, 2022). There are numerous challenges with implementing team-based care models and even when implemented successfully spirituality is seldom addressed (Bamber & Marshall, 2023; & Mendenhall et al, 2022). This has created a system that is dependent on intentional referrals done by the provider or requested by the patient. Operationally this creates a system that is fragmented and unable to adequately address a patient's whole spirituality and their whole BPSS health. There are numerous causes for this, but the majority are the historic separation of church and state, a lack of validation within spiritual tools and assessments, and a lack of spirituality-focused training for providers outside of spiritual specialists (Hall & Powell, 2021; Kestenbaum et al, 2021; & Mendenhall et al, 2022). Because of these other operational areas lack a presence of spirituality. For example, a lack of standardized spiritual tools and assessments and acknowledgment correlates with a lack of note templates within a healthcare facility's EHR (Kestenbaum et al., 2021). There are usually places within a provider's note to address the biological, psychological, and social but outside of spiritual specialists' notes, the spiritual aspects of a patient's care are absent. An additional aspect of spirituality within a healthcare system is spiritual specialists aiding in the fight against burnout and compassion fatigue for providers (Tata et al., 2021). They also can aid in the management of a positive work culture. Mendenhall et al. (2022) point out 9 that this is a significant part of the operational world due to the influence it has on staff sick days, work performance, productivity, and turnover rates. It is shown that these are reduced when spirituality is acknowledged within a provider's life and their patients’ health. Because of these benefits and others, it is important to build up spirituality and its acknowledgment within the operational world. By doing this, providers and the healthcare system can build on the current system of referral-based care and fully acknowledge spirituality within BPSS health. As mentioned before in the other worlds an avenue that can be taken in enhancing spiritual care is to incorporate BHPs. Within the operational world, this would look like the collaboration between BHP's, biomedical providers, and spiritual specialists. However, the dilemma of adequate training to increase spiritual acknowledgment continues to be ever-present. Training The pressing question is then; out of Peek's four worlds which one would be the most advantageous to create a solution and increase the acknowledgment of spirituality within the US healthcare system? Based on how the four worlds interact, literature and clinical judgment it is the opinion of the authors that the most advantageous starting point is the training world and more specifically training BHPs. Training BHPs can increase their understanding of the concept of spirituality and their own comfort in acknowledging spirituality within their holistic care. It would be a moot point to create or enhance current spiritual assessments and tools (clinical), billable codes (financial), and EHR systems (operational) if healthcare providers do not feel comfortable enough to interact with them. BHPs also have a point of contact with the patient and other providers that can aid in pulling together the healthcare system to fully address BPSS 10 health (CFHA, 2022). This is why training BHPs on spirituality will create ripple effects that will enhance the presence of spirituality in the three other worlds. The issue then becomes the current state of the spirituality training world. According to the literature most spirituality training for BHPs is limited to faculty interest and there are few evidence-based trainings (CACREP, 2015; Richards et al, 2023; & Williams-Reade et al, 2019). Also, spirituality training is often limited to diversity classes which focus predominantly on major world religions and not on spirituality (Mendenhall et al., 2021). This can be an issue because of numerous leaders in spiritual care acknowledging the modern version of spirituality and its ever-changing and expanding nature (Hill & Pargament, 2003; Koenig, 2008; & Reinert & Koenig, 2013) Because of this there is a lack of clarity on the current state of spirituality training for BHPs. This is why there is a need for further exploration of the BHP spirituality training world, its strengths, and its weaknesses. Through this exploration, a clear direction in spirituality training and a connection for spiritual care with the other three worlds can be made. Purpose/Design This dissertation walks through the BHP spirituality training world and its connection to the US healthcare system. More specifically, Chapter 1 serves as an overview of the current state of spirituality within the entire US healthcare system through Peeks (2008) four world view. This chapter creates a clear connection between the common issue of lack of acknowledgment of spirituality within healthcare and a possible solution to this within BHP spirituality training. To continue past this overview in Chapter 1 and create a clear picture of the status of spirituality training for BHPs Chapter 2 delivers a systematic review that focuses on all spirituality training/educational interventions. This review outlines the presence of these 11 interventions and their characteristics; demographics, profession of BHP learners, setting, number of participants, type of intervention, educational content, method of instruction, timeframe of training, instructors, curriculum, and validated measures used. It was concluded that there is a lack of consensus on validated measures and on limited evidence-based curricula utilized for spirituality training. However, even amongst these issues, a thematic analysis of the content reveals themes that align with the modern clinical version of spirituality (Koenig, 2008). Those themes are Multiculturalism, Professional Development, Clinical Skills, and Biopsychosocial-Spiritual health. The authors utilized these themes to create a flexible framework/clinical posture for the direction of spirituality training, Spiritual Humility. Spiritual Humility can be utilized to guide future curricula and validated measures. It can also change and expand alongside the ever-changing and expanding concept of Spirituality. To further expand our understanding of BHP spirituality training Chapter 3 outlines the methodology utilized in a mixed methods approach. It provides a description of the quantitative survey being utilized along with the qualitative questions included in this survey. The survey also utilizes a modified version of the validated measure; The Religious/Spiritually Integrated Practice Assessment Scale (RSIPAS V.2). The aim is to assess the level of spiritual integration through the modified RSIPAS V.2 for BHPs and what factors affect this level (i.e., training, experience, demographics, religious affiliation, et.). Through this research this dissertation will help to fill a gap in spirituality training for BHP and in turn increase appropriate and universal acknowledgment of spirituality within the US healthcare system. 12 Conclusion This dissertation explores the current state of spirituality training and aims to generally answer questions such as what is the status of spirituality BHP training? why do they not aid in increasing provider comfort with the term? and can BHPs help fill the gap in spiritual acknowledgment within healthcare? This dissertation also aims to bring attention to the lack of acknowledgment of spirituality within the US healthcare system, the importance of spirituality within holistic healthcare, its universality to all patients/clients and how BHP training plays a part. 13 REFERENCES American Association for Marriage and Family Therapy (AAMFT) (2018). Competencies for family therapists working in healthcare settings. Retrieved from www.aamft.org/healthcare. 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Journal of marital and family therapy, 45(2), 219–232. https://doi.org/10.1111/jmft.12314 Wright, L. M., Watson, W. L., & Bell, J. M. (1996). Beliefs: The heart of healing in families and illness. New York, NY: Basic Books. https://doi.org/10.14475/jhpc.2021.24.4.199 https://doi.org/10.1016/j.jnma.2019.04.002 https://doi.org/10.1037/rel0000467 https://doi.org/10.1111/scs.12603 https://doi.org/10.1111/jmft.12314 CHAPTER 2: EVERYWHERE BUT NOWHERE: A SYSTEMATIC REVIEW ON SPIRITUAL TRAINING INTERVENTIONS FOR BEHAVORIAL HEALTH PROVIDERS Introduction Within the United States (US) healthcare system, spirituality is generally defined as the beliefs, practices, and experiences that create ultimate meaning and purpose (Balboni et al, 2022; de Brito Sena et al., 2021). Spirituality also includes aspects such as secularism, connection, wellbeing and hope and modern definitions include religion as a subpart (Hill & Pargament, 2003; Koenig et al., 2012; Rosmarin & Koenig, 2020). These definitions encompass some dimensions of spirituality but fail to provide a conceptual direction for providers to follow when addressing it within their care. The main reason for this nonexistent direction is due to spirituality lacking a full conceptual breadth, meaning that the concept changes depending on the context of the individual or system and is ever-expanding (Koenig, 2008). Spirituality’s ever-expanding definition and deficiency of clear direction in the US healthcare system has kept its care at arm's length for providers. In fact, most healthcare providers fail to at least acknowledge it within their patient's/clients' healthcare journey. In contrast to this lack of acknowledgment are major healthcare models/frameworks that include spirituality. For example, Engel (1977) presents the Biopsychosocial (BPS) model as an alternative to the biomedical model. This was due to the limitations of the biomedical model regarding holistic health and its tendency to fragment health into individual parts of a whole (Doherty et al., 2014). The BPS framework fights against this fragmentation and creates avenues for patient’s whole health to be adequately addressed (Mendenhall et al., 2018). Later it became the Biopsychosocial-Spiritual (BPSS) model (Engel, 1977 & Wright et al., 1996). Wright et al 19 (1996) discusses the interplay of patient’s beliefs with healing, medicine and their overall healthcare journey. They provide a starting point for healthcare providers when considering how to interact with a patient, their full BPSS health. Since its conception the BPSS has provided an overall framework that allows and encourages inclusive and equitable whole health care. In summation it champions the message; everyone’s whole health, including spirituality, deserves to be addressed. However, despite the groundwork done by the BPSS framework, a patient's whole health continues to be fragmented and aspects such as spirituality continue to be left out and unacknowledged (Kusnanto et al., 2018; & Mendenhall et al., 2021). There is a plethora of reasons for this, but the most significant is provider comfortability in acknowledging spirituality (Delbridge et al, 2014; Errington, 2017; Mendenhall et al, 2021; & Saad et al, 2017). This lack of comfort is commonly connected to the training that these providers receive on spirituality (Jones et al, 2021). Because of this it is the aim of this systematic review to explore the question; who is being trained on the concept of spirituality and how are they being trained? More specifically, due to their role within healthcare and the lack of exploration in their spirituality training. This review will explore the training of behavioral health providers (BHP). To accomplish this the authors will present an up-to-date summation of religion, spirituality; their relationship with each other and with BPSS health. Lastly it will provide a comprehensive exploration of spirituality trainings, what they are teaching, what they are not teaching and the general direction of current spirituality training for BHPs. 20 Theoretical Underpinnings As mentioned before the difficult aspect of exploring spirituality is its expansive definition and its lack of operational boundaries. This makes it difficult to measure within research (Koenig, 2008). Because of this it is important to establish an expansive and non- restrictive theoretical framework that will dissuade the authors from being anchored to one definition or view of the concept spiritually. Existential theory can aid in this as it correlates with the human experience and the freedom of choice in finding meaning and purpose (Kaufmann, 1956). Much of the human experience with spirituality relates to freedom and how an individual finds meaning and purpose in their lives (Kaufmann, 1956; Yalom, 1980; & Frankl, 2006). Existential theory provides a succinct conceptual framework from which to understand the human connection to spirituality (e.g., personal understanding of the human existence, freedom of choice, meaning of life, values, and defining purpose in life) (Kaufmann, 1956). The theory provides a solid foundation by which this systematic review and the relevant findings will be grounded. Existential theorists believe that individuals can find meaning, purpose and other spiritual concepts through a plethora of sources that include but is not limited to themselves, higher power, external objects/persons, spirituality, and religion. Individuals can search for truth with an open mind to avoid placing preconceptions, labels or categories on oneself and others. Existential theory is self-defining, expansive and conceptually universal to humanity. The same can be said about the concept of spirituality and more specifically spirituality within clinical care (Koenig, 2008). This is also why it is important to establish a clinical version of spirituality to better understand its elusive and contextual dynamic and how it is universal to all. 21 No One Left Behind Koenig (2008) presents a modern clinical version of spirituality while exploring the pros and cons of spirituality within research. Koenig (2012) reinforces his clinical version by describing spirituality as “once based on religion, spirituality is increasingly viewed as a broader concept that each individual defines for themselves” (p. 91). Within this modern clinical version it is posited that spirituality is a universal part of general human existence and encompasses all identities including ones such as secularism (a term used for those who are not religious). This is useful because a clinician’s responsibility is to use inclusive language/terms to provide equitable care for diverse populations. By using this clinical version and definition, the authors come alongside Koenig in stating that spirituality is a universal part of the human experience, and more so spirituality is a universal part of everyone’s BPSS health. This framework expands spirituality and allows a freedom from borders or restrictions while simultaneously accounting for individual aspects/identities that are connected or are an inherent part of spirituality (e.g., religion, secularism, meaning, purpose, connection, peace, culture, social location etc.) (Koenig, 2012). Lastly it aids in the authors mission of leaving no one behind in BPSS healthcare. With the underpinnings of existentialism, and Koenig’s clinical version of spirituality the authors propose the, “No one left behind” framework. This framework will aid this systematic review in openly exploring the current state of BHP spirituality training. It is also the authors aim to ascertain future directions of curriculum, and education to better connect training to clinical practice. 22 Literature Review Spirituality and Religion When exploring spirituality and its place in healthcare and in BHP training it is important to highlight the concept of religion. Overall, there is a consensus on the operational definition of religion within healthcare (Koenig et al, 2012; Hill & Pargament, 2003; Oman, 2018; & Pargament et al, 2013). Religion is straight forward and is usually defined as the beliefs, practices, and rituals related to the divine/sacred (Koenig et al, 2012) and historically religion and spirituality has been seen as one in the same (Koenig, 2008; & Oman, 2018). Additionally, this inseparable view of religion and spirituality is evident in past research and literature (Ferngren, 2014). However, modern healthcare providers and researchers have begun to differentiate spirituality from religion (Balboni et al., 2022; Currier et al., 2019; Delbridge et al., 2014; Ebenau et al., 2019). In this modern view, religion is positioned as being an important subpart within the larger concept of spirituality. It is also important to highlight the relationship between religion and BPS health outcomes and how these connect to spirituality. The operational definition of religion commonly correlates to better physical (Cotton et al., 2006; & Ferngren, 2014), psychological (Richards et al., 2023; & Rosmarin & Koenig, 2020), and social (Oman, 2018) health outcomes which makes it applicable across BPS health (Delbridge et al, 2014; Mendenhall et al., 2021). More specifically Religion is linked to improved recovery rates, fewer symptoms of depression, lower rates of suicide, lower rates of substance use, and improved social relationships (Richards et al., 2023; & Rosmarin & Koenig, 2020). Literature connecting religion to BPS health has been present within healthcare throughout history and has increased exponentially since the year 2000 23 (Koenig, 2012a). In fact, since 2000 there have been over 100 systematic reviews on religion and the individual parts of BPS health (Oman, 2018). Under the modern view of religion, the connection to beneficial health outcomes now falls within the concept of spirituality. However, even though religion is a more straight forward and operational subpart of spirituality, it shares the common struggle of a lack of acknowledgment by most healthcare providers and BHPs (Abdulla et al., 2019). In summation, religion is a subpart of spirituality, the second S of the BPS(S) framework. In addition, regardless of the connection to better health outcomes religion joins other subparts of spirituality (i.e., secularism, meaning, purpose, connection, wellbeing, hope, etc.) in going unacknowledged. Spirituality and BHPs There have been numerous attempts to capture and operationalize spirituality for research and clinical purposes (Clark & Emerson, 2020; de Brito Sena et al., 2021; Reinert & Koenig, 2013; Steinhauser et al., 2017). While all share similar aspects there are unique differences and variability. However, despite this, there is still correlations between acknowledging spirituality and better health outcomes for BPSS health (Clark & Emerson, 2020; Delbridge et al., 2014; Richards et al., 2023; Wilson et al., 2018). Accordingly, medical, and behavioral health professions acknowledge the importance of spirituality within their standards of care (AAMFT, 2018; CACREP, 2015; JCAHO, 2021). This is due to spirituality connecting to a plethora of cultures, social locations, and identities and their BPSS health (Anders et al., 2021; Fair, 2021; Salami et al., 2022; & Sprik & Gentile, 2020). This is overly evident for BHPs who deal with spirituality in both medical settings (Balboni, 2013; Oman, 2018; & Richards et al, 2023) and in 24 traditional behavioral health therapy (Rosmarin & Koenig, 2020) which creates a clear connection between BHPs and acknowledging spirituality within healthcare. This connection between BHPs and spirituality is present in their current training through aspects such as multiculturalism and cultural humility (Anders et al., 2021; Kondili et al., 2022; Mendenhall et al., 2021; & Wilson et al., 2018). Because of this BHPs are primed to acknowledge spirituality within all forms of healthcare and for all individuals. Multiculturalism has been a dominant guide in BHP training to assess their readiness to interact with diverse patients/clients and their diverse backgrounds and identities (Kondil et al., 2022) and spirituality is often included in this diversity. Most programs discuss parts of spirituality (i.e., mainly religion and cultural belief’s) through the lens of cultural humility, which is the understanding that all identities are complex, and this understanding is never fully realized but should continuously evolve throughout one’s life (Hook et al., 2017; & Tervalon & Murray-Garcia, 1998). This continuous growth aims to create a sensitivity and acknowledgment of all aspects of culture and should include spirituality. Despite this aim BHP training lacks a clear direction in connecting spirituality to care. Within BHP training the concept is touched on minimally by way of faculty interest or diversity classes. (CACREP, 2015; Richards et al, 2023; & Williams-Reade et al, 2019). Also, within BHP training, spirituality is often limited to one of its subparts (i.e., religion) by way of a singular focus on major world religions (Mendenhall et al, 2021). This inadequate state of spirituality training lacks a clear direction but displays a clear reason for why BHPs continue to feel uncomfortable when addressing spirituality (Errington, 2017: & Williams- 25 Reade et al, 2019). This inadequate state of training creates a dilemma that the authors label as the “Missing S.” The Missing S The “Missing S” is when BHPs fail to acknowledge spirituality within their assessments, plans, and treatments for their patients/clients BPSS health (Ferrell et al., 2020; & Mendenhall et al 2021). Additionally, it is when BHPs do not address their uncomfortable feelings and avoid the concept of spirituality all together (Gillilan et al., 2017; Lloreda-Garcia, 2017; Rosmarin et al., 2021; Tehranineshat et al., 2019). In doing this they maintain a hesitancy in their care and fail to connect spirituality to its evident BPS health outcomes (Kwok & Kwok Lai Yuk Ching, 2022; & Saad et al., 2018). This dilemma can be detrimental to healthcare due to its effects of increased discrimination, decreased access to care, increased unmet needs, worsened mental health, and much more (Azhar et al., 2022; Dein et al., 2012; Kalánková et al., 2021; Martin et al., 2010; & Michlig et al., 2022). These effects stem from inadequate training and cause an increase in BHPs discriminatory reactions and a lack of respect for spirituality and its subparts (Brown, 2010; Fadiman, 2012; Moghaddam et al., 2013). Because of this BHPs fail in their responsibility to mitigate the “Missing S” dilemma within their BPSS care and within healthcare. A lack of general direction in spirituality training for BHPs creates a need for clarity and this clarity will hopefully address the "Missing S” dilemma. A clear direction in BHP training will allow BHPs to acknowledge the “Missing S,” work through their discomfort or misunderstanding of the concept and care for BPSS health in its entirety. To provide insight into this clarity and direction a comprehensive review of the current state of spirituality training for BHPs was done. There have been multiple reviews of spirituality training for other health care 26 professionals (Jones et al, 2021; Paal et al, 2015; & Rykkje et al, 2021) and while these reviews are helpful, they provide little insight into BHPs training. Aim and Research Questions The aim of this systematic review is to provide clarity and direction for spirituality training by exploring spiritual educational interventions for BHPs; their implementation, and to answer the following questions: 1) How are spirituality and spiritual care incorporated into all types of educational interventions for BHPs? 2) Do these interventions account for the modern clinical version of spirituality and its universal application to humanity? 3) Do these trainings differentiate spirituality (i.e., religion, secularism, meaning, purpose, connection, wellbeing, and hope), from religion (i.e., beliefs, practices, traditions and rituals related to the sacred.) Methods Search Strategy A systematic search was conducted in November 2022 to identify studies that detailed spiritual care training with BHPs. The authors utilized the following databases in the search: PubMed, CINAHL, and PsycINFO. These three databases were chosen to explore spirituality educational interventions across healthcare fields and environments in relation to BHPs. PubMed is a major journal for biomedical literature and focuses on medicine in general (NIH, 2023). CINAHL explores literature predominantly within nursing literature but also includes allied health literature (EBSCO, 2023). Nurses are also one of the major healthcare fields to explore 27 spirituality within their individual and team-based care (Balboni et al, 2022; & Oman, 2018). PsychINFO is the leading journal for the American Psychological Association (APA) and BHPs (APA, 2023) It explores most of the literature on behavioral health and social sciences research and interventions (APA, 2023). These databases provide a comprehensive overview of spirituality training for BHPs across the healthcare environments and fields. Cochrane Library and PROSPERO were also searched for ongoing systematic review protocols and published reviews about spirituality and training for BHPs. After testing and validating our search in PubMed the authors translated the search strategy for use in CINAHL and PsycINFO. Three researchers independently conducted the initial screening of titles and abstracts of articles identified through the search. The full-text articles were also reviewed by three researchers for inclusion. Inclusion/Exclusion Criteria The inclusion/exclusion criteria were defined using the PICOS (see Table 1) approach which defines population, intervention, comparisons, and outcomes relevant to the review (Cook & West, 2012). We considered all primary studies, regardless of design, as eligible for inclusion if they examined spirituality within training, education, or curriculum for BHPs from the year 2000 to 2022. Data extraction A two-step data extraction process was applied to synthesize the data for the final discussion. Firstly, available data was systematically identified and documented. Extracted data was collected in the COVIDENCE systematic review online screening tool. Through 28 COVIDENCE each article was assessed thoroughly to extract the information in a threefold manner. 1. The characteristics of the articles: demographics, profession of learners, setting, number of participants, if the setting was secular or faith based, if the article differentiates spirituality from religion (see Table 2). 2. The characteristics of the educational intervention: type of intervention, educational content, method of instruction, timeframe of training, instructors, and curriculum (see Table 3). 3. Validated measures: measures, purpose, subscales, and results (see Table 4). Even though measures are a part of the exclusion when comparing the interventions, it is still important to ascertain the presence or lack thereof for future directions and research. To ascertain a current general direction of BHP spirituality curriculum the content of these interventions were subjected to a thematic synthesis (Thomas & Harden, 2008). This was done to parse out analytical themes from curriculum being taught. The data was analyzed separately by three independent researchers, who defined descriptive themes from just the extracted data and then defined analytical themes in relation to the data and researdch questions. The themes emerging from the extracted data were discussed by the group to avoid bias towards a certain outcome. The group of three consisted of the lead author, a prior abstract and full text screener, and a researcher not priorly involved in the project. The purpose of this team was to avoid bias and create themes true to the data and results of this review. Only the lead author was aware of the research questions, with the other two being informed of them after the first step of the thematic synthesis. 29 Results From 9295 preliminary hits, 53 full text articles were assessed for eligibility and 37 were selected for the final review. A Prisma diagram was developed to provide readers with a stepwise process of the search parameters (see Figure. 1). Setting Out of the 37 articles there are 19 educational interventions done in academic settings, 17 in clinical settings, and one in a professional conference. Additionally, 23 of these settings are secular and 14 are faith based. Profession The interventions include the following BHP professions; social work (n = 19), counseling (n = 10), clinical psychology (n = 7), psychiatry (n = 6), marriage and family therapy (n = 3), counselor education (n = 1), and school counseling (n = 1). There are 23 interventions that include only one BHP and 14 that include more than one BHP. Of the interventions that include more than one BHP, 13 are labeled as interprofessional and one is a mix of BHP master’s level students. Interprofessional training happens when two or more professions are taught to work together in creating a collaborative treatment plan surrounding common goals (Green & Johnson, 2015). Intervention Type There are four different types of educational interventions: 1. Frameworks/models (n = 5). 2. Standards (n = 2). 3. Direct patient care (n = 19). 30 4. Academic (n = 11). The first is based on interventions that propose frameworks/models surrounding spirituality training. These interventions focus on a specific theory or model that guides the general direction of their training. An example of this is the Discrimination Model which Polanski, 2023 uses to break down supervision of BHPs surrounding spiritual concepts to its simplest form. The second type, proposed standards, are guidelines for specific BHP training. These provide a formal direction of skills and competencies for BHPs regarding spirituality within their care. The third type is direct patient care which is training that is clinically applied to the patient/client during the program and does not include a structured course. Psychiatry residency programs are considered underneath this type since residency is not an academic portion of their training and focuses on patient care within clinical settings (Award et al., 2015; Campbell et al., 2012; Grabovac et al, 2008; Kozak et al., 2010; McCarthy & Peteet, 2003; & McGovern et al., 2017). The last theme alludes to when BHPs receive an educational intervention within the academic portion of their training, and this occurs by way of an instructor and within a specific academic course. This includes classes such as a practicum class, or field work class which is still a structure course residing in the academic portion of a BHPs training while they are actively providing care to patients/clients. Differentiates Spirituality from Religion The “No One Left Behind” framework allows for the definition of spirituality to be self- defining, but also points out that spirituality is not just limited to religion but encompasses aspects such as secularism, meaning, purpose, connection, wellbeing, hope, and social locations/identities. Therefore, the authors propose that to differentiate spirituality from religion 31 the articles must; define spirituality, separate the term from religion, and discuss the relationship between them. It is believed that doing this will add value to an educational intervention surrounding the topic of spirituality (Koenig et al., 2012). There are 19 interventions that report a written definition of spirituality and 18 who do not report a written definition (see Table 3). Four of the 18 interventions that do not report a written definition of spirituality, in text, still differentiate spirituality from religion within their discussion (See Table 2, Bowser et al., 2022; Kozak et al., 2010; Thiel et al., 2020; & Zollfrank et al., 2015). In summation there are 17 interventions that adequality differentiate spirituality from religion according to the framework, four* that partially do, and 16 that do not. Themes The findings of the thematic synthesis have been organized into 4 overarching themes: 1. Professional development. 2. Clinical skills. 3. Multiculturalism. 4. BPSS. Professional Development A wide range of content and educational interventions were utilized to help providers develop professionally while integrating spirituality into their care. To better align with professional development, it is important to first highlight the proposed standards amongst the interventions (Bohecker et al., 2017; & Hagedorn & Gutierrez, 2009). Standards provide BHP professionals and academic programs avenues to assess BHPs on, their spiritual care, spiritual integration ability, ethical considerations, and growth in attuning to spiritual issues. For example, 32 the standards proposed by the Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC), measure aspects of care like the “ability to identify limitations of one’s own understanding of a clients religious or spiritual expression and the ability to make appropriate referrals and provide resources” (Hagedon & Gutierrez, 2009; see Table 3, Standards). The proposed ninth Council for Accreditation of Counseling and Related Educational Programs (CACREP) standard highlights referral skills that providers should possess when interacting with chaplains and spiritual leaders (Bohecker, 2017). They also provide considerations on how to assess for spiritual integration skills within BHP training. Even more important are aspects of development such as transference/countertransference and boundaries and this came up in educational interventions for psychiatrists (Grabovac et al., 2008; & McCarthy & Peteet, 2003;). Lastly are the ethical obligations of including spirituality into care and the ethical guidelines that surround spiritual care. Educational interventions like the program curriculum for psychiatrists enacted by McGovern et al., (2017) emphasize that holistic care has an ethical obligation to include spiritual care. There are also interventions that focus on ethical spiritual care practices and when to refer to a spiritual specialist (i.e., chaplains). This provides guidelines on scope of practice regarding spiritual concepts. The importance of addressing ethical guidelines in spirituality is overtly present in 14 of the interventions (Award et al., 2015; Bandini et al., 2019; Blaclock & Holden, 2018; Bohecker et al., 2017; Hagedorn & Gutierrez, 2009; Kozak, 2010; McGovern et al., 2017; Pate & Hall, 2005; Puchalski et al., 2020; Rawlings et al., 2019; Roberson et al., 2020; Robinson et al., 2016; Thiel et al., 2020; Zollfrank et al., 2015). 33 Self of The Provider Self of the provider is another aspect of professional development in BHP training and more specifically in spirituality training. A BHP brings with them a multitude of values, morals, relationships, competence, education, social locations, and trainings that impact care (Sude & Baima, 2020). Self of the provider work can be important in making ethically sound and unbiased decisions when integrating spirituality into care. All 37 educational interventions within this review acknowledge that an awareness of one’s own spirituality is important in its training and care. Some do this by allowing time for providers to attempt spiritual interventions on themselves (n = 6). Some include telling of personal spiritual stories (Sloan-Power et al., 2013), completing a spiritual life map that directly highlights spiritual experiences (Buser et al., 2013), meditation exercises (Birkenmaier et al., 2005), painting exercises and drama therapy activities (Meyer, 2012), screening tools (i.e., Faith and belief, Importance, Community, Address in Care (FICA), and Spiritual belief system, Personal spirituality, Integration in spiritual community, Ritualized practices, Implications for medical practice (SPIRIT)) ( Piotrowski, 2013) and the creation of a spiritual genogram (Bowser et al., 2022). Other articles encourage growing in this awareness of spirituality for oneself and one’s clients. They develop this awareness by way of small group discussions, creating personal definitions of spirituality and religion, and self-exploration. For example, Polanski (2003) proposes a supervision model that encourages counselors to explore their own personalization skills when it comes to acknowledging spirituality in care. They did this by utilizing the discrimination model which reduces supervision to its simplest form and allows for an increase in self-awareness. Still other interventions use process-oriented discussions to explore concepts 34 like, psychiatrists’ fears and reservations about discussing spirituality with their patients (Awaad et al., 2015), how to develop a relational spirituality (Callahan & Benner, 2018) and how to be a compassionate presence and the role of a BHPs personal spirituality (Puchalski et al., 2020). Clinical Skills According to this review a major component of clinical skills is the ability to have general skills in spiritual care. Four of the interventions label these skills as being a Spiritual Generalist (Bandini et al., 2019; Robinson et al., 2016; Szilagyi et al., 2021; & Theil et al., 2020), and deal with direct care of a patient within a clinical setting (i.e., primary care, hospital unit, etc.). According to Szilagyi et al., (2021) a Spiritual Generalist “addresses patients’ spiritual distress and strengths to collaborate with spiritual care specialists” (p. 3). They provide a direct list of basic spiritual care skills that they believe each provider should possess. Even though the term of “Spiritual Generalist” is limited to four interventions, the skills required are present within all 37 of the interventions. Those skills include assessment and acknowledgment (n = 15), chaplain referrals (n = 11), and recognizing spiritual distress within client’s lives (n = 5). Most of these interventions attempt to educate BHPs on recognizing spiritual distress when clients present in medical or therapeutic settings. Multiculturalism Multiculturalism is commonly defined as “the quality or condition of a society in which different ethnic and cultural groups have equal status and access to power but each maintains its own identity, characteristics, and more” (APA, 2023). Within this review and the 37 interventions there is an emphasis on making BHPs aware of the multicultural aspects of spirituality. This theme is present within 18 of the educational interventions and spans through 35 all four types of interventions (frameworks/models, standards, direct patient care, and academic). These interventions include education on different religions, cultures, spiritual/faith traditions, worldviews, and perspectives. This is done to increase the cultural humility of BHPs, so they can provide equitable care. Cole (2020) teaches this concept of multiculturalism through the ecological framework, which is an emphasis on the person:environment relationship. This allows social workers to view their clients within the context of their personal and community environments. There is also Fowler’s theory of faith development which is used in a proposed counseling supervision model (Ogden & Sias, 2011). Through this theory, students acknowledge that faith or spirituality is globally universal and is a significant part of general humanity. Still other interventions create specific educational milestones; ethnic, racial, and cultural considerations (Lennon-Dearing, 2012), diverse spiritual and religious perspectives (Bohecker et al., 2017), cultural context of spiritual beliefs (Hagedorn & Gutierrez, 2009), spiritual worldviews (Campbell et al., 2012), global care (Ferrell et al., 2022), major world traditions/religions (Kozak et al., 2010; McGovern et al., 2017; & McMinn et al., 2014) and secular worldviews (Robinson et al., 2016 Thiel et al., 2020). These interventions aim to educate BHPs on the specific dynamics of spiritual multiculturalism, and they also emphasize the need for BHPs to grow in their understanding that spirituality is a universal part of BPS health, even for those who identify as secular. In an interprofessional workshop they require social workers to define concepts like spirituality, culture, cultural humility, and cultural competence (Rawlings et al., 2019). In another interprofessional workshop on spiritual generalists’ social workers, and clinical psychologists are taught to develop respect for all spiritual traditions (religious or secular) when assessing for spiritual distress (Robinson et al., 2016). Thiel et al. (2020) 36 emphasizes diverse “spiritual talk” that spans multiple identities and social locations (i.e., secularism, religion, culture, etc.) within their interprofessional workshops. In an academic class for social workers, they aim to increase spiritual sensitivity of course material by examining spirituality within human behavior and examining cultural competence within oneself (Callahan & Benner, 2018). BPSS Only two articles make a direct reference to BPSS in their spirituality training (Birkenmaier et al., 2005; & Campbell et al., 2012). In a direct patient care intervention, a psychiatry residency program requires second-year residents to spend four hours developing their own BPSS evaluation (Campbell et al., 2012). The second intervention is a framework/model, and it is a one-time training for social workers where they discuss BPSS health and how it fits into clinical work (Birkenmaier et al., 2005). Outside of these two interventions, other direct patient care interventions connect spirituality to overall health or mental health (n = 3). Also, the proposed ninth CACREP standard puts forth an emphasis to learn about the impacts of spirituality on health issues and other dynamics of health that one would label BPSS in nature (i.e., medical issues, trauma, addiction, sexuality, etc.) (Bohecker et al., 2017). Altogether six interventions make a direct connection of spirituality to other aspects of health (BPS). Discussion This systematic review of spirituality training for BHPs reveals numerous educational interventions (i.e., classes, workshops, program curriculum, supervision models, one-time training, etc.). However, only two interventions use a curriculum that is evidence-based 37 (Puchalski et al., 2020; & Szilagyi et al., 2021), the Interprofessional Spiritual Care Education Curriculum (ISPEC). The settings of these studies are a palliative care unit (Szilagyi et al., 2021) and the Veterans Administration (Puchalski et al., 2020). Additionally, following the common dilemma in spirituality research, ISPEC’s success is based on its collaborative content but not on its validated measures. In the absence of these measures, the ISPEC training does follow-up evaluations at three, six, and twelve-months post-training. These evaluations focus on how ISPEC is implemented into an organization but a universal measure that displays the successful implementation and growth of spiritual generalist skills is needed. The other 35 also lack consistent validated measures. This is mostly because their implementation, content, and instruction are limited to; faculty/administrational interest and diversity classes. Only three used validated measures to solidify intervention outcomes (Boheck et al., 2017; Crabtree et al., 2020; & Sloan-Power, 2013) (see Table 4). Additionally, not one of these measures is repeated in other spirituality training, and all three studies chose separate measures due to different stud