Advancing Spiritual Care Through Research

Kenneth I. Pargament & Julie J. Exline Working with Spiritual Struggles in Psychotherapy: From Research to Practice. New York: Guilford Press, 2022

Katherine M. Piderman, Ph.D. BCC, NACC

Chaplain Coordinator of Spiritual Research and Associate Professor of Psychiatry, Mayo Clinic, Rochester, MN

It’s hard for any of us to commit to reading a book these days, especially one over 300 pages long, but I strongly encourage you to consider Working with Spiritual Struggles in Psychotherapy:  From Research to Practice by Kenneth Pargament, Ph.D. and Julie Exline, Ph.D.  It is packed full of clinical vignettes, quotes, theory, research, and references.  All are intended to inform and guide investigators and clinicians from many fields, including chaplains.  Indeed, after reading the beginning of Chapter 1 about Nancy who was sitting at the bedside of her beloved daughter in the emergency room and grappling with the even more devastating reality that she was mortally wounded, I knew the book would have a lot to teach me.  Nancy is described as, “lost at sea, with nothing solid to grab on to, nothing to ground her, and nowhere to go” and later, as experiencing “questions that rushed in to fill the void [left by her daughter’s death]” (p. 3, 4). How familiar those phrases sound to me, as I reflected on my time with others in crisis and my own. Suffice it to say that I was hooked, and the book became a regular companion for me in my reading chair during the cold Minnesota winter months. 

Pargament and Exline state that spiritual struggles are “pervasive, painful, and pivotal” (p. 12). As chaplains, we know that well.  Day after day, we are called to enter the lives of people experiencing ragged and raging spiritual struggles.  We learn over time that pietistic words and deeds or other “spiritual band-aids” are rarely effective.  Instead, we put on the boots of courage and hope, and we “stand in the gap” (Ez. 22:30), present with respectful attention and compassion to the spiritual struggle before us. The authors offer helpful suggestions that can augment our ability to do this, including tools and approaches to honor the darkness and disorientation of these times and encourage trust.   We may be blessed to experience the pivotal nature of spiritual struggle in an encounter, but the authors remind us that what we see in one, or even several sessions, is not “the end of the story.”  A person’s spiritual journey continues through life and may evolve in “new and surprising directions” (p. 240).  They include research demonstrating that spiritual struggle does not always end well.  It may, in fact, lead to brokenness and decline.  However, they also include studies that point to the development of wholeness and growth, as one works through spiritual struggle.  In truth, we never really know how things will work out for those we serve, but I’d say that to be a chaplain and stay a chaplain, we must believe that the latter is always possible.  The evidence provided helps me to be humble but also, to remain hopeful.  It also begs the need for more research in this area.

The authors define six types of spiritual struggle:  divine struggles, demonic struggles, interpersonal spiritual struggles, struggles with doubt, moral struggles, and struggles of ultimate meaning (p. 9).  Subsequent chapters describe each in depth and offer suggestions for addressing them.  As I recall being in the murky, turbulent sea of emotion related to spiritual struggle, these sections give me anchors to hold on to and help me to think more deeply about what might be going on and how to help.  They also are motivation for me revisit my own spiritual struggles, past and present – another tremendous plus from my reading, as I have learned that understanding myself is essential in caring well for others.

Pargament and Exline indicate that spiritual struggle often lurks beneath the surface of a presenting issue.  I expect we have found this to be true many times when called to minister to someone sobbing inconsolably, recalcitrantly withdrawn, or complaining about every aspect of care.  The authors affirm the importance of being open to “the more” because of the distress, danger, and tremendous potential inherent in spiritual struggle.  They encourage growing competence and comfort in this area, something that chaplains seek by virtue of their profession. 

There is an old story about a family rift that becomes mended over a long night of sharing.  As dawn breaks, one of the youngest discovered the two most at odds, drinking coffee together at a spot overlooking the farm.  She said to them with joy, “You made it to morning!”  (Shea, 2006).  When I reflect on the privilege of chaplaincy, I think of those “long nights” with patients, loved ones, and/or staff when spiritual struggle fills the air and people, including me, are “shaken to the core” (p. 327).  I see my role, my gift, and my calling as being present and still in struggle and supporting those involved the best I can. At times though, it seems, as Yeats says so poignantly in his poem, Stolen Child, (1889) “the world’s more full of weeping than you can understand.” Sometimes the gap between “weeping” (or raging or desperate silence) and understanding can seem insurmountably vast.  Reading Working with Spiritual Struggles in Psychotherapy:  From Research to Practice has helped to decrease the gap for me and has increased my understanding, and I expect it will for others who read it. 

In closing, thank you, Dr. Pargament and thank you, Dr. Exline for your dedicated commitment to advancing the understanding of spiritual struggle and teaching us more about how to provide care.  May your book be widely read, and may it be a beacon to guide chaplains and all readers as they continue to hone their ability to be and to serve amidst spiritual struggle, always remaining resolute in the belief that “morning” may come.   


Shea, John. (2006). The relentless widow: Spiritual wisdom of the gospels for Christian preachers and teachers. Collegeville, MN: Liturgical Press. 

Yeats, William B. (1889).  “Stolen Child.” The wanderings of Oisin and other poems.   London: Kegan Paul, Trench, & Co.

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