Hungarian Psychotherapists’ Experiences of the Cooperation with Spiritual Directorsand Pastoral Counselors: A Qualitative Study

There has been a constantly growing interest towards the themes of psychotherapy and spirituality in the past decades. The questions and experiences concerning spirituality can come up and play an important role in the psychotherapeutic relationship. Often another helping relationship, spiritual direction or pastoral counseling is already present in religious people’s life, before or at the time of starting psychotherapy. In our research we tried to find answers to the question of how psychotherapists approach cooperation with spiritual directors and pastoral counselors, what attitudes and experiences they have in this regard. In the research semi-structured in-depth interviews were carried out with 31 Hungarian psychotherapists, and they were analyzed with the method of Grounded Theory. Four main categories evolved during the analysis of the interviews. In the first main category, where there is no cooperation between the helping professionals, codes refer to the attitudes, whether the psychotherapists would be open to cooperate, what professional considerations they would follow, and in what framework the cooperation could be realized. In the second main category the psychotherapist and the spiritual director work parallel with the patient, without contacting each-other, in the third the psychotherapist is in contact with the spiritual director/pastoral counselor, and in the fourth the psychotherapist evaluates the experiences of the cooperation.


Introduction
In the last decades a great opening can be noticed in the field of psychotherapy towards the theme of spirituality, and this interest is ever growing (BARTOLI 2007; PIEDMONT, in his innovative study describes spirituality as the independent, sixth factor of personality (1999). According to him, spiritual transcendence refers to the 'capacity of individuals to stand outside of their immediate sense of time and place to view life from a larger, more objective perspective' (PIEDMONT 1999, 4). This transcendent perspective leads to a greater sense of unitedness and common fate with others, which strengthens a sense of commitment to others. Spiritual transcendence is a fundamental capacity of the individual, a source of intrinsic motivation that directs behaviors (PIEDMONT 1999).
Religion / spirituality is an important socio-cultural factor in Europe (ROSTA 2010), and worldwide (Gallup International Millennium Survey 1999). Gallup surveys between 1992 and2012 show that 55-59 % of the US population considers religion very important in their own life, 24-29% considers it fairly important, and 92% confesses himself/ herself a believer. 72% of the population agrees with the statement, that 'my whole approach to life is based on my religion' (BIENENFELD & YAGER 2007, 178). Therefore it is not surprising that 'when dealing with a serious problem, two thirds of Americans prefer a psychotherapist with spiritual values' (VIETEN at al. 2013, 129), and one third would preferably turn to a professional who integrates these values into psychotherapy. ROSE and her colleagues (2008) who in their study asked expressly patients found that according to 63% of the responders it is appropriate to discuss religious issues in therapy, and 25% would personally require to do so.
In Hungary two-thirds of the population identify themselves as religious, and within that 10-15% of the population practices religion in their church (attends church on a weekly basis) (TOMKA 2010). There has not yet been any research in Hungary that could reveal the extent to which patients would desire to discuss spiritual / religious issues in psychotherapy. Qualitative research results came out on how therapists' attitude towards spirituality appears in therapy and how it can affect patients (TOMCSÁNYI et al. 2017).
In the field of psychotherapy after the initial distancing an augmentative opening is discernible towards the theme of religion/spirituality. First, in the 1960s a major change could be felt, and since the 1980s the number of publications on religion/spirituality has increased rapidly (BARTOLI 2007). This growing interest in spirituality has little effect on psychotherapeutic training though, despite the needs expressed among psychotherapists (CROOK-LYON Et al. 2012;ELKONIN et al. 2014;HOFMANN & WALACH 2011;TOMCSÁNYI et al. 2017;VIETEN et al. 2013;VIETEN et al. 2016).
The qualitative studies can show the most detailed insights about the fine questions of psychotherapeutic practice: how themes of religion/spirituality emerge in the settings. CROSSLEY and SALTER (2005) interviewed 8 clinical psychologists in their study. Using the method of grounded theory, they analyzed the appearance and path of spiritual contents in the psychotherapeutic space. Two major categories evolved according to their results: the first one refers to the uncertainty surrounding spirituality, both in terms of grasping its notion, and in regard to its treatment. The second major category summarizes the experiences of therapeutic work with spirituality: the interviewees tried to keep pace with the patient's need, accept the faith and spiritual contents brought in by the patient, and follow the patient's thoughts, emotions and phantasies concerning spirituality.
Using also the method of grounded theory, MAGALDI-DOPMAN and colleagues (2011) analyzed the religious and spiritual identity development of 16 American psychotherapists in relationship with their therapeutic work. The interviewees shared that the spiritual contents brought in by the patients found them unprepared and made them work hard, so meanwhile they began to change as well. This influenced the way how they entered into interaction with the patient. The journey shared with the patient ended with various outcomes: among the reactions we find the total avoidance of spiritual contents; uncertainty and questioning of the therapist's own spiritual identity; and shared spiritual development and experience with the patient. BLAIR (2015) in his GT-based study interviewed nine psychotherapists, ana lyzing how their own spirituality influenced their practice. The integration of their psychotherapeutic and spiritual identity proved to be a long and difficult process. Two major observations emerged from the interviews. One's own spirituality influences directly the therapeutic work, and it is the psychotherapists' task to work out the harmony between their own spirituality and their perception of the broader professional environment. KNOX and colleagues (2005) analyzed patients' interviews using the method of Consensual Qualitative Research. She interviewed patients who turned to not spiritually oriented therapists, while facing not specifically spiritual problems. She was interested in when and how spiritual contents emerge in psychotherapy, and whether the patient experiences it positively or negatively, and what characterizes these positive and negative experiences. She found, that in those cases, when the patient had a positive experience, it was always the patient himself/herself who brought up the topic since it was related to some other actual problem he/she was facing. In cases ending with a negative experience it was in half and half proportion that the patient or the therapist brought up the theme of spirituality, while the patient did not feel understood and accepted.
A Hungarian study also analyzed the emergence of spirituality in psychotherapy. The study -to which this paper is closely connected to 2 -analyzes semi-structured interviews with 30 Hungarian psychotherapists, applying the grounded theory analytical strategy. The aim of the study was to explore how spiritual issues are understood by psychotherapists in the course of psychotherapy, and what happens to these issues and experiences in the therapeutic setting. As one possible solution among a variety of attitudes and working methods, psychotherapists shared examples in which -while facing their own competency dilemmas -they referred the patient to a spiritual director. All this leads to the issue of inter-professional cooperation, which is the subject of our present study.

Spiritual Direction
Spiritual direction is an important form of accompanying people in their religious experiences. Believers often turn to a spiritual director on a regular basis, in order to deepen their relationship with God, and to develop their faith life. RICHARDS and BERGIN (2002) define spiritual direction, as 'guided reflection about the spiritual aspects of one's life' (RICHARDS & BERGIN 2002, 273). According to MAY's definition spiritual direction can apply to any situation in which people receive help, assistance, attention, or facilitation in the process of their spiritual formation. This applies not only to deepening one's personal realization of one's relationship to God, but also to the dynamic livingout of that realization in the actions of daily life. (1982,6) Actual life events and life tasks are discussed in spiritual direction as well, but the emphasis is on their spiritual / religious dimension (TOMCSÁNYI et al. 2009).
As far as the frames are concerned, spiritual direction can be part of spiritual life through years and even decades, with monthly or rarer meetings. Another form of spiritual direction is when on a retreat the participants can engage in regular personal discussions about their spiritual experiences (TOMCSÁNYI et al. 2009).
Both mentally healthy and ill people can seek spiritual direction. It can happen that an already ongoing regular relationship of spiritual direction has to cope with a situation when during this period of time the directee faces a life crisis or develops psychopathological symptoms. On such occasions spiritual life and the relationship with God can be affected by the change of mood pointing towards pathological dimension. This can further burden and frighten the directee already struggling with problems, because an important resource, a basic relationship (his/her relationship with God) which serves as a source of meaning for him/her changes due to the mental illness. For this reason it can be a of great help for the spiritual director, if he/she is familiar with mental disorders, and on that basis he/she can better reflect on the joint appearance of psychological and religious/spiritual states in the life of the directee.

Pastoral Counseling
Seeking out pastoral counseling can also be a part of spiritual life. 'Pastoral counseling is the conversation about life issues in the widest sense of the word' 3 (DEBRE- CENYI et al. 2004, 152). The goals of pastoral counseling are to a certain extent overlapping with the goals of psychotherapy because both handle life issues, conflicts and the resolving thereof, but they use different approaches and skills [basic knowledge and different competencies]. One of the intentions of the pastoral counselor is to help the person verbalize his/her feelings and thoughts. Another aim is to help the person to find his/her own solutions of the questions, problems brought to the pastoral counselor, by mobilizing the inner resources available. Also, pastoral counseling could help the client -only if demanded -to strengthen his/her faith, to renew his/her relationship with God, or to discover it as a novelty.
Religious / spiritual questions can be a subject of pastoral counseling but not in all cases: only if the client requires it. (DEBRECENYI et al. 2004). People claiming themselves non-religious can also receive pastoral counseling, often without religious / spiritual questions being verbalized during the sessions. At these times spirituality is only present implicitly through the person of the pastoral counselor.
But often those who seek specifically pastoral counseling choose this possibility exactly because they would like to understand more of and work on the spiritual aspects of their problems as well, these possibly being part of their conflicts. It becomes important for them in the helping relationship to work on this aspect facing various life situations, such as planned divorce, mate choice, mourning or dilemmas of saying yes to giving birth to a new life.
Under the umbrella term of pastoral counseling we can meet various trends and schools. Their main direction is defined by the discipline the pastoral counselor is using to complement their theological knowledge; these can be psychology, soci ology, or biblical knowledge (TÖRÖK 2013). In Hungary, pastoral counseling is mainly based on the person centered approach, and there is a strong tradition of the theological -biblical approach as well TÖRÖK 2013).

Patterns of Cooperation between Psychotherapy, Spiritual Direction, and Pastoral Counseling
Psychotherapy, spiritual direction and pastoral counseling are helping relationships all of which can deal with the question of spirituality -but in different ways, and from different aspects. Different are the goals, the competencies, as well as the basic knowledge applied in these helping relationships. Psychotherapy handles the psychological aspects of religion / spirituality. The psychotherapist can allow the theme of spirituality to come up in the psychotherapeutic space to the extent the patient requires it, but stays between his / her own competency limits. As an example, he/she can work with how the patient's representation of God affects the patient, but the rightness of this God representation is no more his/her competency. CORVELEYN (2000), Belgian psychoanalyst, calls this approach 'benevolent neutrality' and refers to it as the basic characteristic of European psychotherapeutic culture. A different approach is the world of the psychotherapies integrating spirituality, which has spread most of all in the United States. How this integration is realized differs among schools and approaches. TAN (1996) classifies the therapies addressing directly spirituality (also using specific religious tools) as models of explicit integration as opposed to the approaches of implicit integration, which fall closer to the attitude of 'benevolent neutrality', although working with spiritual orientation (paying special attention to the upcoming spiritual / religious issues, relying on a specialization in training). In some cases the necessity of cooperation between helping professionals emerges. VIETEN and colleagues (2013) based on their research outcomes state that it is a basic competency for a therapist to be able to recognize religious/spiritual conflicts in clinical practice. In these situations the authors say that the therapist has to refer the patient if it is necessary, or should cooperate with other professionals, including professionals from the religious/spiritual field as well -while distinguishing his/her competency limits. The literature on the cooperation between the diverse professions is very poor, almost completely missing. It can be assumed that the reason for this can be that on the American continent spiritually oriented therapies are more frequently used in such situations (so the question of cooperation emerges less often). European literature in turn does not really explore or bring in such psychotherapeutic situations as a topic, when the cooperation between these fields (psychotherapy, pastoral counseling, and spiritual direction) would be needed or it becomes a practice.
In KOENIG's handbook (1998) WEAWER wrote a chapter on the cooperation between religious leaders and mental health professionals. He outlines that cooperation is most of all missing, although a great percentage of American people first turn to their pastor, religious helping professional when they face problems of their mental health, family or other relationships. Clergy direct 10% of those who first turn to them to mental health care. Cooperation could improve if both parties would benefit from getting further training which is at this time insufficient. RICHARDS and BERGIN (2002) in connection with the broader topic of spirituality and psychotherapy also write about the cooperation with spiritual directors. They mention cases in which psychotherapists directed their patients to spiritual direction when some kind of spiritual crisis or blockage emerged in therapy. They also mention situations when the spiritual director is the one directing the patient to psychotherapy, who otherwise would probably never have sought out or accepted psychotherapeutic help without this suggestion. Apart from the positive experiences, the authors also mention cases when the spiritual direction affected the mental health of the patient negatively and led to emotional problems, which brought the patient to psychotherapy later on. They suggest the contact between the two helping professionals (psychotherapist and spiritual director) in favor of the patient to improve cooperation and understanding, obviously only with the agreement of the patient. They outline the significance of how great help it could be for the patient to join a religious community or keep engaging himself/herself in spiritual direction after the ending of therapy in order to preserve the therapeutic results achieved. (RICHARDS & BERGIN 2002). HEFTI (2011) in her paper writes about the cooperation taking place at a psychiatric ward, more specifically introducing the practice at the Swiss Langenthal Clinic for psychosomatics, psychiatry and psychotherapy. The clinic uses the extended biopsycho-social-spiritual model as a theoretical framework: it integrated religion and spirituality into the therapeutic concept from the beginning. Its basic assumption is that in all mental illnesses there is always an existential and therefore spiritual dimension which should be explored. Patients can integrate spiritual/religious goals into their treatment plan: e.g. regaining hope and meaning, strengthening the relationship with God, etc. Spiritual goals are discussed later on in the interdisciplinary team of which the pastoral counselor is a full member. To evaluate not only the symptomatic improvement but the impact of religiosity on the treatment, an outcome study was conducted at the clinic. Their results show that integrating spiritual intervention into treatment enhanced therapeutic effectiveness.
The Hungarian work team led by Tomcsányi published a series of articles on the competencies of spiritual direction -pastoral counseling -and psychotherapy TOMCSÁNYI et al. 2008;TOMCSÁNYI et al. 2009), mentioning also the possibilities of cooperation. In the article written on the spiritual direction (TOMCSÁNYI et al. 2009) a case is presented -among others -in which the situation of an ongoing double helping relationship (parallel psychotherapy and spiritual direction) is evaluated. In psychotherapy a spiritual conflict (regarding the representation of God) comes up, which the psychotherapist chooses not to handle on his own, instead he suggests the option of a parallel accompaniment, with the agreement of the patient. In another case the spiritual direction gets to a point, where the directee faces such mental problems which require (also) psychotherapeutic help.

Research question
In our study we examined how Hungarian psychotherapists looked at the cooperation with spiritual directors. What experiences they have had: how and in what framework this cooperation took place. Facing our research question the interviewees also shared experiences about their cooperation with pastoral counselors, so later we broadened the interview questions, separately addressing the questions of cooperation with spiritual directors and pastoral counselors. Results were analyzed with a qualitative research method, the Grounded Theory, which allows to systemize the experiences of an unknown area with the preservation of the variegation of the unique cases (CHARMAZ 2006;CORBIN & STRAUSS 2015).

Sample
In our research our target group consisted of Hungarian psychotherapists who have been practicing for at least 10 years, we asked them about their experiences with spirituality 4 and psychotherapy, focusing on several separate topics. We followed the HUNGARIAN PSYCHOTHERAPISTS' EXPERIENCES 85 EJMH 14:1, June 2019 steps of the theoretical sampling using the criteria that matched our research question (CHARMAZ 2006). We took the interviews in three turns, following the questions and patterns that emerged during the analysis (coding) of the already collected interviews.
The 31 interviewees in the final sample were between 40 and 80 years of age: a third of them men; two-thirds women; one third from outside the capital city; twothirds from Budapest. Since some of them practiced more than one method, overlaps were observed with respect to therapeutic orientation. In all, we interviewed twelve psychoanalysts, five cognitive therapists, four hypnotherapists, seven family therapists, and eight psychodrama therapists.
We did not ask direct questions about religious or denominational affiliation, let alone personal conviction or faith. However, all interviewees spontaneously expressed to us how they related to the churches and some of them also shared with us their personal attitude towards spirituality and the transcendental. Although only four of them belonged to a church, about one half of the whole sample declared themselves to be personally interested in spirituality. (TOMCSÁNYI et al. 2017, 241)

Instrument and Data Collection
We used semi-structured interviews in the research. The formulation of the interview guide and the later reformulation took place in the research team, with the integration of the experiences of the previously conducted interviews, according to our constructivist research paradigm (HENWOOD & PIDGEON 2003). The 33 interviews were conducted by six members of the research team. All interviews were conducted in person, the premises were sometimes the interviewee's workplace, consulting room, in exceptional cases the home of the interviewee or a neutral place. The interviews on average sessions lasted 120 minutes (the shortest: 90 minutes; the longest: 200 minutes). The transcriptions of the conversations were checked and anonymized by the interviewer before the beginning of the coding process.

Research team
A broader research team, consisting of 10 people participated in the literature revision, in the planning of the research and in the data collection, while the outcomes discussed in this article were analyzed by a smaller group of 4 researchers. The leader of this part of the research is a clinical psychologist, family therapist, having also a degree in theology. Two professionals in this smaller team are psychotherapists (one of them trained in psychoanalysis, psychodrama and family therapy, and one in CBT) and clinical psychologists, the fourth member of the team is a mathematician with a qualification in mental health.

Researchers' self-reflection and assumptions
In our research we did not rely on any previous hypotheses -according to the method of Grounded Theory; indeed, we aspired to follow an inductive logic while analyzing the outcomes of the interviews. At the same time our previous professional experiences influenced how we understood the evolving patterns during the analyzation; so we recorded these in memos 5 (CHARMAZ 2006;2008) which are side notes by the interview texts in service of constant self-reflection on our own understandings as researchers. Memos were formulated at the time of interviewing, constantly throughout the process of interview analyzation, and at the research team discussions. We would highlight the following from among our primer professional experiences: in our practice more of us have faced situations of parallel psychotherapy and spiritual direction. We teach or used to teach at the (postgradual) pastoral counseling specialist training course of the Semmelweis University, where the issue of the clients' referral to psychotherapy and the cooperation is often raised as a question in the practice of our students. As staff members of the pastoral care center run in connection of the training course we meet various demands of the clients turning to us. Among these demands pastoral counseling, spiritual direction and also psychotherapy can be named. At times it is the client who defines what kind of specialist they want to turn to, but it is also common when they need help in the orientation and selection of the most appropriate form of help. Sometimes such patients who have been in psychotherapy turn to us, and for them the psychotherapeutic work and the outcomes of it are important. Still, they are missing that they cannot work with their dilemmas regarding religious life and spirituality in that helping relationship, therefore they seek further help. In these cases the possibility of parallel psychotherapy and spiritual direction arises. Our preliminary experiences and assumptions therefore focused primarily on emerging needs, but we did not really have any idea what could be seen as a form of collaboration in the practice of psychotherapists. It was also imaginable for us that, despite the needs, there was hardly any cooperation and also on the contrary, that there existed such a practice. Regarding the emerging practice our question was that if there were such a practice, how would the psychotherapists evaluate it in terms of helpfulness / effectiveness. We assumed that the forms of cooperation would differentiate further according to this aspect.

Method of Analysis: Grounded Theory
As research method we chose a qualitative research tool, called Grounded Theory (CHARMAZ 2006). As the detailed description of the research method and the ethical considerations we published in one of our former articles (TOMCSÁNYI et al. 2017), now we only outline the major information necessary to understand and interpret the method of analysis and the code tree representing the outcomes of our research.

Interview Coding
Coding followed the systematic method of Grounded Theory, in which constant comparison method (CHARMAZ 2006;2008) was employed to find possible patterns both within individual interviews and across interviews.
Topics were identified and ordered through a three-level coding process (open, axial and selective coding, per STRAUSS & CORBIN, 2015). The first step of analysis was data reduction: a line-by-line reading of interview transcripts, and the identification of conceptual units. (TOMCSÁNYI et al. 2017, 243) After this with the comparison of data we produced meaningful content units -open codes (such as 'In case of loyalty conflict the psychotherapist clarifies the patient's negative judgments related to psychology') which were then arranged along emerging patterns under axial codes (such as 'The Psychotherapist Works with the Conflict of Psychotherapy and Spiritual Direction', 2.3. axial code).
Axial codes led to a search for new data and the creation of new open codes, making the coding process circular. Codes were given labels and memos and they were repeatedly compared with each other, and applied to the new incoming interviews). This process was continued until the saturation of conceptual units, thus producing the ultimate selective codes.
[The Psychotherapist and the Spiritual Director Work Parallel with the Patient without Contacting each other', 2. selective code -authors' supplement] In the final system of codes, axial codes thus described how and under what circumstances the comprehensive phenomena highlighted in the selective codes were realized in the therapeutic space. The open codes, on the other hand, contained the specific variations under the axial codes. (TOMCSÁNYI et al. 2017, 244) During the process we used the text analytic software ATLAS.ti, by which we wrote down and store the outcomes.

Results
During the coding of the 33 interviews the results were arranged in a code tree consisting of 68 open codes,16 axial codes and 4 selective codes. The code tree is presented in the Appendix of our paper. Answering the research question the results show how the interviewed psychotherapists relate to the cooperation with spiritual directors and pastoral counselors, what patterns of cooperation have been established, and what experiences are linked to these patterns.
In what follows, we summarize the contents of the code tree. The central patterns of cooperation are presented in the selective codes, we introduce these. The variations within the main patterns are presented by the axial and open codes in the code tree, some parts / branches of them we highlight and refer to.

selective code: The Psychotherapist does not Cooperate with a Spiritual Guide or a Pastoral Counselor
Some of the interviewed psychotherapists have not yet worked together with spiritual directors and so they do not have such an experience. Still, their attitudes about it move on a wide scale: Some of them would deny cooperation referring to various professional considerations (1.1 axial code). Others would be open to cooperation and verbalize the possible forms of it (1.2 axial code). Again others are open but they would cooperate only with the fulfillment of some conditions (1.3 axial code). The experiences when the cooperation fizzled out belong also to the first selective code: in such cases the psychotherapist would have been willing to cooperate with the spiritual director or pastoral counselor but on their part (1.4. axial code) or on the part of the patient (1.5 axial code) the openness was missing. The question regarding cooperation brought up the dilemma of the professional boundaries, which was reflected by the interviewees (1.6 axial code).
We now highlight some of the patterns / findings of this first selective code. Some of the psychotherapists argued against the parallel psychotherapy and spiritual direction, with reference to some professional standpoints. They referred to the different anthropology of the two areas, for this reason they would not consider it possible to have a dialogue, common thinking and shared usage of language between the areas (1.1.3 open code). Another argument says that 'spirituality is part of the soul, so the separation would be harmful' (1.1.1 open code), as one of the interviewees worded it. This interviewee would consider it less risky for the patient to 'have one hand helping him/her', even if this hand is inexperienced regarding the issues of spirituality/religion. This attitude outlines the importance of integration, meanwhile reflects the danger of the lack of competencies, when it is only the psychotherapist who works with the spiritual aspects of the patient's questions.
Among the psychotherapists who have not had occasion to work together with a spiritual director several say that they would be open to it and would consider it acceptable. Some would simply acknowledge if their patient would turn to a spiritual director (1.2.1 open code). Even more openness marks the standpoint of those who would be willing even to get in touch with and consult with the spiritual director if their patient attended spiritual direction at the same time while being in psychotherapy (1. The possibility of cooperation raises the question of competency limits among psychotherapists. They try to map and translate for themselves the meaning of spiritual direction and pastoral counseling (1.6.1, 1.6.2 open codes). Naturally we did give a definition of these concepts at the course of the interviews, still, we often noticed that if an experience is not linked to the definition (such as the psychotherapist has not experienced it in practice), the clarification of the definition itself could not be enough to apply it in practice. Regarding the competency limits, the [demarcation of] differentiation between psychotherapy and pastoral counseling -even the question of legitimacy of pastoral counseling was raised, as well as questions regarding the competency of pastoral counseling (1.6.3 open code) and the relationship between spiritual direction and psychotherapy (whether these can be integrated in one helping relationship, or rather the work on the psychological level and on spirituality/religion should be handled separately (1.6.4, 1.6.5 open codes).

selective code: The Psychotherapist and the Spiritual Director Work Parallel with the Patient without Contacting each other
The second selective code refers to experiences in which the patient attends psychotherapy and spiritual direction parallel, the two helping professionals know of each-other, but they only cooperate implicitly, they do not contact each-other. Three axial codes which group the main topics belong to this selective code. In what follows we present these, and we also mention some open codes which represent specific variations of the axial codes.

axial code: The Psychotherapist and the Spiritual Director Work Parallel with the Patient without Contacting each other
When psychotherapy and spiritual direction runs parallel, the relationship and also the issues of spiritual direction can appear in the psychotherapeutic space (2. If some contents regarding spiritual direction already appeared in the psychotherapeutic space, some psychotherapists start to work with it, and consider it important to integrate the effects of spiritual direction (2.1.3 open code). One of the psychotherapists reflects on this phenomenon in the following way: 'It is important . . . that I always ask the patient what the spiritual direction for him / her was good for, knowing that one always goes somewhere for a good reason' (2 I 106). Apart from integration, some therapists also seek to strengthen the positive effect of spiritual direction, enhancing and completing this way the therapeutic effect (2.1.4 open code).

axial code: In Parallel Accompaniment the Psychotherapist Has Control over the Therapeutic Frames of Spiritual Guidance
The second axial code includes such codes and citations in which psychotherapists confess how they handle therapeutic frames in situations of parallel psychotherapy and spiritual direction. So in this work method life events were discussed from two different aspects. In psychotherapy the psychical and relational aspect were discussed, and in spiritual direction the aspect of religious and spiritual life.
Another pattern is also about the handling of therapeutic frames, when the psychotherapist respects that the patient has a spiritual director, and the issues belonging there are discussed in that relationship (2.2.3 open code). Most often the case is that it is already a part of the patient's life, that he/she has a spiritual director, when he/she decides to turn to a psychotherapist. The psychotherapist then accepts this situation and lets the spiritual direction run parallel with the psychotherapeutic process.
Finally, there were also cases in which the psychotherapist explicitly tried to regulate, designate what issues the patient should bring into psychotherapy, and what issues into the spiritual direction (2.2.4 open code).The differentiation suggested that issues of spiritual life, of relationship with God should belong to the spiritual direction.

axial code: The Psychotherapist Works with the Conflict of Psychotherapy and Spiritual Direction
In some cases parallel psychotherapy and spiritual direction conflicted with each other. Psychotherapists share how they tried to work with this conflict. When the contents of psychotherapy and spiritual direction conflicted each other some therapists let the patient balance between these (2.3.1 open code). In some cases the conflict was not about contents, but the patient got into a loyalty conflict between the two helping professionals. In these situations -for example when the spiritual leader takes a stand against psychotherapy -the psychotherapist tries to clarify the patient's negative judgments related to psychology (2.3.2 open code) in order to help him/her resolve this inner conflict. In other cases when the patient gets into a loyalty conflict between the two helping professionals, the psychotherapist starts to work with the relational dimension unfolding it in therapy (2.3.3 open code). An example is when the psychotherapist starts uncovering the theme of distrust in therapy or recognizes the resistance against therapy in the way of how the importance of the relationship with the spiritual leader changes compared to the importance of the relationship with the therapist. In the next quotation the psychotherapist starts working with the psychological task of bargaining, of creating personal opinion and that of confronting other's opinions; this work begins related to the conflict evolving between spiritual direction and psychotherapy. The patient's spiritual director suggested a longer, silent, solitary retreat to the patient, which the psychotherapist did not consider beneficial for the patient because of his actual mental state:

. . . it would have been bad if I had said to him that he was a free man, he should decide it. It would have been also bad, if I had said to him, that no way, he could not do it, because this was a therapy, and I wouldn't let him continue if…[thoughtfully] Instead, I told him we should look at it together, the viewpoints should be confronted with each other. First of all, it was a good elaboration of the situation, and also he (the patient) could experience how he could confront another man, without getting in trouble.
(8 SVK 70) In further cases the conflict between psychotherapy and spiritual direction remained unsolved. The patient got stuck with the integration, which in extreme cases ended with the breaking up of the psychotherapeutic relationship because of this situation (2.3.4 open code).

selective code: The Psychotherapist is in Contact with the Spiritual Director / Pastoral Counselor
Another form of cooperation between psychotherapist and spiritual director or pastoral counselor is when they not only know of each other, but they also get in contact with each other. The third selective code summarizes these quotations and codes. The four axial codes present the main patterns belonging to this selective code: when cooperation means referring the patient to the other helping professional (3.1 axial code), or when the psychotherapist and the spiritual director consult with each other (3.2 axial code). A separate axial code (3.3 axial code) collects the cases of consultation with the pastoral counselor. Finally, those forums of cooperation are named, which give place to cooperation between psychotherapists and both spiritual directors and pastoral counselors, but not in connection with the treatment of the same patient (3.4 axial code).

axial code: Cooperation Happens through Referral
The most basic form of cooperation is when the two helping professionals get in contact with each other when one refers the patient to the other. The psychotherapist sent the patient over to the spiritual director when the patient was facing some kind of spiritual conflict, or problem concerning faith (3. 1.1 open code). On the other hand, the spiritual director directed the patient to therapy, while recognizing that he/she was struggling with a psychological illness (3. 1.3 open code). Several illnesses were named in the case examples, such as depression, compulsion, borderline personality disorder and psychosis.

axial code: The Psychotherapist and the Spiritual Director Consult each other in the Case of the Patient's Parallel Accompaniment
In the praxis of psychotherapists it has also happened that they consulted with the spiritual director of their patient. In some cases they were the ones who initiated the consultation (3.2.1 open code). In most cases consultations were made because the therapist's impression was that the two processes got in conflict with each other. A couple of times the consultation did not lead to any change, the cooperation did not improve. In extreme cases it happened that the psychotherapist referred the patient to the spiritual director (and ended therapy) as a result of the irreconcilability of the contradictions of the two processes, in order to protect the patient's integrity ( In other situations the cooperation led to a significant improvement in the harmonizing of parallel accompaniment. On these occasions the psychotherapist explained the psychodynamics, the symptomatic behavior, which helped the spiritual leader to count on these, and stand by the patient in a way which was in harmony with the psychotherapy. A good example of this is the story of an anorexic girl who besides family therapy also attended spiritual direction. Even though at a point the two processes entered into contradiction, after consultation they became supportive of each-other. The main source of problem was that the spiritual director tried to encourage the girl to eat, which led mostly to resistance. When the therapist explained this and also the family dynamics to the spiritual director, she became more patient and did not urge the girl. A good spiritual direction relationship was preserved, which could now support psychotherapy. Obviously, there were also cases when it was the spiritual leader that initiated the consultation (3.2.2 open code), either personally or on the phone. These times the consultation aimed mostly at a better understanding of the patient's mental state.

axial code: The Psychotherapist Works Together with a Pastoral Counselor on the Apropos of Common Case
In the interviews psychotherapists also shared experiences when they worked together with a pastoral counselor in relation with the same patient. The most typical form of cooperation with the pastoral counselor was that pastoral counseling and psychotherapy alternated with each other, and at the time of referral, the process was discussed by the professionals (3.3.1 open code). As one of the interviewees says: 'It's often the case that pastoral counseling is a kind of the precursor of psychotherapy' (7 SVK 128). This could mean a socialization to psychotherapy or it could also mean that during the process of pastoral counseling the counselor -after evaluating the case -considers it necessary to refer the patient to psychotherapy.

axial code: The Psychotherapist Collaborates with Spiritual Directors / Pastoral Counselors on other Professional Forums
Psychotherapists work together with pastoral counselors and spiritual directors not only on the grounds of helping the same patient, but there are also other forums of their cooperation which are presented in the 3.4 axial code. One form of cooperation is the request of consultation (3.4.1 open code): on these occasions the psychotherapist contacted a professional qualified in theology to consult about a case anonymously, which touched the question of spirituality causing challenge to the psychotherapist. So these times it was not the patient's own spiritual leader to whom the therapist turned, since the patient had not even had one, it was not a parallel accompaniment. Nevertheless, the psychotherapist initiated the consultation and made use of the opportunity either at a single time or regularly as a process.
As a further form of cooperation, several interviewees shared that they attended supervision groups in which spiritual directors and pastoral counselors also participated (3.4.2 open code). An interviewee outlines that these interdisciplinary supervision groups helped him most in cooperation, because this way he was able to get to know the work of a pastoral counselor at an experiential level, which helped the further connection and common thinking.
A further forum of cooperation between psychotherapists and pastoral counselors is the institutional framework, for example working in a team with hospital chaplains, or when pastoral counselors work at a psychiatric ward or in a prison (3. 4.4 open code).
Finally, several psychotherapists also mention as a form of cooperation that it serves as an aftercare, that after ending the therapy -the patient can be directed back to a pastor and a religious community which surrounds him/her with a retaining power (3.4.3 open code).

selective code: The Psychotherapist Evaluates the Experiences of the Cooperation with the Spiritual Director / Pastoral Counselor
Psychotherapists evaluated the cooperation with the spiritual director from the perspective of the patient's condition and the experiences of the therapeutic process. They mentioned favorable and negative examples as well, regardless of the form of cooperation, which could have been any of the above discussed. Codes and quotations collected in the first axial code (4.1 axial code) refer to the effects of the spiritual direction itself, how the psychotherapist evaluated the impacts of it on the patient's condition. The second and the third axial codes analyze the cooperation with the spiritual director demonstrating both negative (4.2 axial code) and positive (4.3 axial code) examples. These we present summarized and integrated in the next section.
In cases when the patient attended both psychotherapy and spiritual direction regardless of the fact whether the two professionals contacted each other or not -the psychotherapists often evaluated how much the patient benefited from this situation according to them. Positive experiences (4.1.1 open code) were mostly marked by the background factor of the competency limits having been respected. Positive experi ences were also in connection with the quality of spiritual direction. Psychotherapists found that spiritual direction had a positive psychological effect on the patient. They experienced the two helping relationships to be complementary and supportive. This meant on the one hand that the spiritual director supported the psychotherapy, encouraged the patient to share his/her conflicts, for example relational problems with the therapist. The spiritual director reinforced the patient's psychotherapeutic motivation and commitment. On the other hand, the spiritual direction itself indirectly carried such psychological unintended effects (which added to the therapeutic effect and outcome (4.1.4 open code). In the following example more positive effects of the spiritual direction are outlined by the psychotherapist: This girl -an anorexic patient -was caught up in the fight between her dad and the maternal grandparents. She went to a spiritual director, a Calvinistic pastor. According to the girl's sharing it helped her a lot that the spiritual direction strengthened her faith. She could attend spiritual direction on a weekly basis, while they were able to come here only once in two -three weeks, since they weren't living in the town of X, so that was the best we were able to organize. I too had the impression that spiritual direction strengthened her faith, it made her a little freer compared to the strict faith of her grandfather. So the grandfather gave rigid instructions on how one should believe, what was righteous, what was not reputable. . . This young Calvinist pastor helped this girl a lot either in Bible interpretations or in the flexibility of religion.
(2 I 58) As an indirect positive effect of the spiritual direction the girl's anxiety eased. This was partly due to the strengthening of her faith, on the one hand, and to the weekly meetings with the spiritual leader, which meant security for her, on the other. The dissolution of beliefs related to too rigid religious standards further contributed to the resolution of the girl's loyalty conflict in the family.
A patient suffering from symptoms of anxiety also showed signs of improvement after her faith got stronger. In this example the psychotherapist gives a more detailed explanation of how this positive effect prevailed, and through what mediating factors: I remember this anxious patient who had been coming to me again and again. It was very important for her when she also started to attend spiritual direction, she was accompanied there as well, and she also came to me, so the effects of the two processes added up. The fact that she found faith reduced her anxiety. She was very alone, very lonesome, her family members died, she didn't really have any living relatives. She raised her son alone. Then, this community, and the faith, that Someone cares for her gave her a background. Let's say there is God who counts on her. So in cases like this when there is no available family support, then it's really important for someone to have faith. My task is easier this way also, since I cannot take care of her forever.
(2 I 32) The experiences of positive cooperation were not only useful for the patient, but a part of the psychotherapists confirmed the increment of these situations for them personally. In these cases psychotherapists emphasized that in the cooperation with the spiritual director their understanding became more enriched, they learned from each-other (4.3.2 open code). Some of them outlined as a positive outcome of the cooperation, that the good cooperation itself can have a therapeutic effect on the patient, it even can lead to a corrective emotional experience (4.3.4 open code): 'We, the care givers should be in unison with each other, because in the patient's life those relationships have been damaged where the union of the people caring for her was missing. This is my experience' (31 JZS 2, 125).
The negative experiences of spiritual direction running parallel with psychotherapy were also related to the competency limits, this time to the transgression, i.e. the failure of keeping these limits. Another background factor of the negative experiences of cooperation was the quality of the spiritual direction, and the effect represented by the contents. It could have happened that -because the spiritual director had no proper knowledge of mental disorders -his / her feedback which was adequate as far as the spiritual/religious life was concerned still affected the patient negatively, in the patient's actual mental state.
As we presented earlier, consultation (3. 2. axial code) in some cases brought solution to the problems arising from the missing understanding of the symptomatic dynamics, and good cooperation could be realized between the psychotherapist and the spiritual director, while in other cases consultation did not reach its aim.

Discussion
In our paper we explored and systemized the different patterns of cooperation between psychotherapists, spiritual directors and pastoral counselors, which outlined theoretical guidelines useful for practice. We find it remarkable that among the interviewed psychotherapists several have faced such situations in their practice when they worked together with spiritual directors or pastoral counselors either directly or implicitly, without contacting each other.
Our results show that the attitudes and practices concerning the form of cooperation show a great variability. This may also be due to the fact that this issue has not yet been discussed on a broader professional forum. There is a great uncertainty concerning the possible and professionally correct ways of cooperation. Psychotherapists most often rely on their own -not cross checked -practice and the professional rules adopted from other areas when trying to handle situations of cooperation as best as they can. However, they often grope in the dark somewhat 'blindly'. From the unfolded patterns of cooperation it can be seen that this approach can lead to constructive solutions intuitively, yet these preconceptions can also be misleading. As an example, we demonstrate this phenomenon with the distinction of spiritual direction and pastoral counseling, which caused a problem for many of the interviewees, despite the definitions given in the course of the interviews. For instance, psychotherapists with Protestant background often answered questions without the distinction of the two helping relationships, referring only to pastoral counseling, often with automatic exchange of words in the answers, regardless of the question. The background factor can be that in the Protestant tradition the role of pastoral counseling is very significant, while spiritual direction is barely visible (WHITLOCK 2002). The prior practical knowledge of the psychotherapist influenced him/her in a way that the questions raised in the interview evoked the experiences related to pastoral counseling. It is very notable that indeed psychotherapists -among them even those who do not call themselves believers / religious -who often cooperate with referrals coming from ecclesiastical circles (spiritual directors and pastoral counselors), usually used the terms adequately in the interviews without any difficulty. They cooperated sufficiently with spiritual directors and pastoral counselors even without explicitly expressing what they meant under these terms. In the competencies what counted the most was the experiential knowledge as opposed to the knowledge of definitions. The phenomenon can be well described by the theory of tacit knowledge, from Mihály Polányi (NAGY 1992). Polányi contradicts the positivist philosophy of science, instead he states, that understanding is always a more complex phenomenon than just the summary of information, it always has a tacit dimension. That is why we are not always aware of the signs we use for identifying things. Therefore, in some sciences practice is needed, the theoretical knowledge is not enough for understanding (NAGY 1992). Concerning the patterns of cooperation in the interviews, we recognized this phenomenon: perception, understanding and practice were mostly led -or misledby this tacit knowledge. In certain cases the explicit wording of the principles of cooperation supplemented the tacit knowledge, but only rarely among psychotherapists who were especially interested in the subject.
We systemized the revealed patterns of cooperation and the positive and negative experiences connected to these patterns in the code tree representing the results of our research, which can serve as a reference point in the cooperation of the psychotherapists, spiritual directors and pastoral counselors. Among the patterns of cooper ation we found the parallel psychotherapy and spiritual direction, either with or without the contact of the helping professionals; the consecutive pastoral counseling and psychotherapy; and the other forums which were not connected to the accompaniment of the same patient. These latter ones gave ground to the cooperation of psychotherapists with both spiritual directors and pastoral counselors.
In the parallel accompaniment of a person in psychotherapy and spiritual direction the two helping professionals know of each other, while working with the same patient. The results of our study suggest that the parallel psychotherapy and spiritual direction is not distracting but complementary, when the competency limits are handled correctly. This is consistent with the literature on spiritual direction which says that it is demanded not primarily because of some actual problem but to deepen religious/spiritual life, to develop the relationship with God and the prayer life (JÁLICS 2013). Actual life events do come up in spiritual direction as well but the emphasis is on a special dimension of these, the spiritual/religious dimension (TOMCSÁNYI et al. 2009;MAY 1982).
Another form of parallel accompaniment of a person in psychotherapy and spiritual direction is when the two helping professionals contact each other, either of them can be the one initiating the discussion. RICHARDS and BERGIN (2002) suggest the contact of psychotherapist and spiritual director for the better understanding and the better cooperation. The consultation can be enriching for both parties, can help resolving conflicts of the two processes if those at a point contradict each other. Our results confirm these: among the interviewed psychotherapists some shared with us how the communication with the spiritual director enriched them, in cases when they contacted each other from the beginning routinely, also in cases when the consultation was aimed at resolving some conflicts. Also, some of the psychotherapists outlined that from the patient's point of view it could also be an advantage of good cooperation that in itself it can have a therapeutic effect, can serve as a corrective emotional experience.
Between psychotherapists and pastoral counselors consecutive helping relationships, so the referral of the patient was the most basic form of cooperation took place. How psychotherapists worded, sometimes pastoral counseling served as a 'preface' to psychotherapy, while at other times functioned as an 'aftercare'. A Hungarian article series on the relationship between psychotherapy, spiritual direction and pastoral counseling argues that it is contraindicated for psychotherapy and pastoral counseling to run parallel, the forum of cooperation could rather be the referral of the patient from one process to the other TOMCSÁNYI et al. 2009). Indeed, we did not meet any case in the interviews in which pastoral counseling and psychotherapy ran parallel, only cases in which the helping relationships replaced each other, and the professionals consulted each other at the point of referral. However, there were situations in which a helping relationship, which started originally as spiritual direction had turned more and more into pastoral counseling, as they started to deal with life issues, without re-defining the frames. In these cases the parallel processes became distracting and interfering.
At the interdisciplinary supervision groups among the members apart from the psychotherapists there are also professionals who work with religion/spirituality professionally. These supervision groups can serve as a great opportunity for both the psychotherapists and religious professionals by enabling them to learn from each other (UTSCH 2005). One possible way of operating such supervision groups is the practice that has spread mostly in the United States, where there are supervision groups specialized on the issue of spirituality / religion. These groups function also as an opportunity for further specialization, since there are special methodological suggestions that help the operation of these groups (ATEN & HERNANDEZ 2004;BAR-TOLI 2007;BIENENFELD & YAGER 2007;POLANSKI 2003). In our research interviews we found that also among Hungarian professionals supervision groups are an important and preferred area of cooperation. Here we would refer to an interviewee who emphasized that the interdisciplinary supervision groups became of primary importance for him, because this way he got to know the work of spiritual directors and pastoral counselors at an experiential level, which helped him later to cooperate.
Request of consultation from a spiritual director or pastoral counselor is also an important forum of cooperation. When for instance in relation with the issue of spirituality/religion the patient struggles with some conflict which exceeds the psychotherapist's competency, asking of consultation can help resolve the problem. In their study on the basic psychotherapeutic competencies VIETEN and colleagues (2013), and VIETEN and colleagues (2016) reckon among the necessary competencies related to spirituality the recognition of psychotherapeutic situations when consultation is needed with professionals experts in spirituality (pastor, rabbi, imam, spiritual director). It is also a possibility in such cases for the psychotherapist to choose another way of solution, to seek further education or to direct the patient over to someone else. But when there is no progress in the solution of the conflict concerning spirituality, in extreme cases it can lead to the interruption of the psychotherapy. We have met such an example in one of the interviews as well. LA MOTHE and colleagues (1998) describe this phenomenon. Using the theory of selective attunement from Stern, they point out how spiritual contents can be excluded from the psychotherapeutic space when the psychotherapist is not able to relate to the subject. Due to their nature spiritual contents can indeed cover, relate to every area of the believer's life. So with their exclusion many other important experiences of the patient can also be excluded which are in connection with the spiritual/religious contents.
Across the above mentioned forums of cooperation it was discernible that the handling of spirituality could cause a great challenge for the psychotherapists. The uncertainty concerning the professionally correct, good ways of cooperation is significant, even the literature provides very little help for the professionals to be able to orient themselves. Cooperation from the part of psychology is needed especially in situations raising most of all existential questions (JASPERS 1987;YALOM 1980). Other helping professions, such as spiritual direction and pastoral counseling also have wisdom and competencies to add to the handling of these extreme situations.

Summary, Outlook
Summarizing the results we can say that various patterns of cooperation emerged from the interviews between psychotherapists, spiritual directors and pastoral counselors, together with the reflections and evaluations belonging to them. Since the handling of spiritual/religious issues can be a great challenge for the psychotherapists in their practice, it would be necessary to detect and manage the causes of these uncertainties. In our opinion this is partly related to the deficiencies of training, partly a challenge of self-knowledge in the area of spirituality/religion, which sometimes only surfaces during the therapeutic work. In the psychotherapeutic training the theme of spirituality/religion is hardly present both internationally (HOFMANN & WALACH 2011;CROOK-LYON et al. 2012), and in Hungary (JÁKI et al. 2016). Based on the above, the acquisition of theoretical knowledge and the acquisition of practical skills and experience in particular can be primarily important in situations when the handling of a conflict concerning spirituality is needed (either on the part of the patient or the psychotherapist).
In the interviews the search for competencies was verbalized and the indication of needs is that it would be good to define guidelines concerning cooperation. In the background of the very different attitudes and experiences regarding cooperation we especially have found the lack of the definition and knowledge of these guidelines. Our results can give ground for further research which would aim to define these guidelines, with the expertise and involvement of psychotherapists, spiritual directors and pastoral counselors. A further part of our research which is on the topic of training and is before publication could, after all, help to make the results accessible and transferable to practice.