empirically supported religious and spiritual therapies

Empirically Supported Religious and Spiritual Therapies

m

Joshua N. Hook, Everett L. Worthington Jr., Don E. Davis,David J. Jennings II, and Aubrey L. GartnerVirginia Commonwealth University, Richmond, VA

m

Jan P. HookThe Arlington Center, Arlington Heights, IL

This article evaluated the efficacy status of religious and spiritual (R/S)

therapies for mental health problems, including treatments for

depression, anxiety, unforgiveness, eating disorders, schizophrenia,

alcoholism, anger, and marital issues. Religions represented included

Christianity, Islam, Taoism, and Buddhism. Some studies incorpo-

rated a generic spirituality. Several R/S therapies were found to be

helpful for clients, supporting the further use and research on these

therapies. There was limited evidence that R/S therapies outper-

formed established secular therapies, thus the decision to use an R/S

therapy may be an issue of client preference and therapist comfort.

& 2009 Wiley Periodicals, Inc. J Clin Psychol 66: 46–72, 2010.

Keywords: evidence-based psychotherapy; religion; spirituality

The relationship between psychology and religion has historically been tumultuous.Many psychologists have questioned the value of religion or criticized religion asharmful (e.g., Freud, 1961; Skinner, 1953). Others have held a more positive andhopeful view of religion (James, 1985; Jung, 1968). Over the years, the attitudes ofpsychologists toward religion have generally become more positive. Many value therole of religion in people’s lives (Shafranske, 1996). Furthermore, research hasgenerally found a positive relationship between religiosity and positive physical andmental health (Koenig, McCullough, & Larson, 2001).The United States population is highly religious. About 92% claim affiliation with

an organized religion (Kosmin & Lachman, 1993) and 96% report a belief in God oruniversal spirit (Gallup, 1995). Furthermore, surveys have indicated that about 90%of Americans pray, 71% are members of a church or synagogue, and 42% attend

Portions of this research were supported by a grant from the American Association of ChristianCounselors to the second author.

Correspondence concerning this article should be addressed to: Everett L. Worthington Jr., Box 842018,Richmond, VA 23284-2018; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 66(1), 46--72 (2010) & 2009 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10 .1002/ jc lp .20626

worship services weekly (Hoge, 1996). Thus, psychologists are likely to encounterclients for whom religion and spirituality (R/S) is an important aspect of their lives.Some psychologists have posited that incorporating R/S into therapy may have

important effects on outcome (Shafranske, 1996; Wade, Worthington, & Vogel,2007; Worthington, Kurusu, McCullough, & Sandage, 1996). Because R/S is oftenvery important to individuals, it may be helpful to match therapy to the religiousbeliefs and values of clients (Worthington & Sandage, 2002). A task force forDivision 29 (Psychotherapy) of the American Psychological Association (APA)evaluated the empirical status of the religious matching hypothesis as promising, butit did not evaluate it as empirically supported as of 2002.R/S therapy has become increasingly popular in recent years (Worthington et al.,

1996). Several professional organizations regularly address issues related to R/Stherapy (e.g., American Association of Christian Counselors, Christian Associationof Psychological Science). There are now several R/S doctoral programs in clinicalpsychology that produce high numbers of R/S therapists each year. Several journalsare dedicated to studying topics related to the integration of R/S and therapy (e.g.,Journal of Psychology and Christianity, Journal of Psychology and Theology, PastoralPsychology). Special issues have been devoted to R/S therapy (i.e., Journal of ClinicalPsychology: In Session). The APA also has a line of books devoted to the topic (e.g.,Aten & Leach, 2008; Richards & Bergin, 2005; Shafranske, 1996; Sperry &Shafranske, 2004).Because R/S therapy is becoming increasingly popular, it is important to assess

whether such therapy is effective. The volume and quality of research on theinclusion of R/S in therapy has increased over the past 25 years (for reviews, seeArnold & Schick, 1979; McCullough, 1999; Smith, Bartz, & Richards, 2007;Worthington, 1986, 1991; Worthington et al., 1996; Worthington & Sandage, 2002).However, although recent advances in R/S therapy are promising, little has beenwritten about the empirical status of such therapies (see Hodge, 2006, for adiscussion of one type of religious therapy). The purpose of the present review is touse the criteria presented by Chambless and Hollon (1998) to evaluate the efficacy,specificity, clinical significance, and effectiveness of R/S therapies.For each of the R/S therapies in the present review, we addressed the following

questions:

* What is the evidence for the efficacy of R/S therapies? Efficacy refers to whether atreatment works under highly controlled conditions. For a treatment to bedesignated efficacious, a treatment must either (a) outperform a no-treatmentcontrol group, placebo, or alternative treatment or (b) be equivalent to atreatment already established in efficacy in a study that has sufficient power todetect moderate differences (Chambless & Hollon, 1998). Furthermore, theefficacy of the treatment must be shown in studies by at least two independentresearch labs. If only one study indicates the superiority of a given treatment, or ifall the studies examining a given treatment are contained within one research lab,then the treatment is designated possibly efficacious. Studies are divided into fivecategories: efficacious treatments, efficacious treatments when combined withmedication, possibly efficacious treatments, possibly efficacious treatments whencombined with existing inpatient treatment, and no evidence for efficacy.

* What is the evidence for the specificity of R/S therapies? Specificity refers towhether a treatment works better than an alternative treatment for a particulardisorder. For a treatment to be designated efficacious and specific, the treatment

47Religious and Spiritual Therapies

Journal of Clinical Psychology DOI: 10.1002/jclp

must outperform an alternative treatment such as a psychopharmacological orpsychological treatment (rather than simply a no-treatment control) in at leasttwo independent research labs (Chambless & Hollon, 1998).

* What is the evidence that gains made in R/S therapies are maintained at follow-up? Although follow-up studies are sometimes difficult to interpret due toproblems such as clients pursuing additional treatment and different retentionrates (Chambless & Hollon, 1998), evaluating the long-term effects of R/Stherapies is important.

* What is the evidence for the clinical significance and effectiveness of R/Stherapies? Clinical significance addresses whether or not the changes that occurredas a result of a treatment are large enough to be clinically meaningful (Chambless& Hollon, 1998). Effectiveness addresses whether a treatment can be shown towork in actual clinical practice (Chambless & Hollon).

* What is the evidence for matching client characteristics to R/S therapies? It hasbeen proposed that incorporating R/S into therapy may be helpful for clients whoare highly religious, but may not be helpful for clients who are not highly religious(Wade et al., 2007).

When discussions of specificity, follow-up, clinical significance, effectiveness, andmatching are omitted from a section, the reader can assume that there are currentlyno data that address this question.

Method

When conducting the present review, decisions had to be made about how to defineour search and apply the criteria set forth by Chambless and Hollon (1998). Welimited our review to investigations that examined an R/S therapy for a mentalhealth problem that occurred in an individual or group therapy format. Theexamination of treatments for medical problems (e.g., Cole, 2005) or specificreligious interventions that occur outside of a therapeutic context, such asintercessory prayer (see Hodge, 2007 for a review), were not included. Also, eachtherapy included was explicitly R/S in nature and utilized sacred practices andwisdom (e.g., ascribing readings from a sacred text). Many therapies have roots inR/S traditions but do not explicitly integrate R/S into therapy (e.g., some meditationand mindfulness therapies). Such therapies were included only when they explicitlyintegrated R/S into therapy. Importantly, because the purpose of this review was todetermine the empirical status of R/S therapies, only randomized clinical trials(RCTs) were included (cf. Smith et al., 2007).To identify outcome studies of therapies that incorporated R/S, we searched

PsychINFO, Social Sciences Citation Index, and Dissertation Abstracts Internationaldatabases with combinations of the following keywords: religion, spirituality,counseling, therapy, and outcome. After conducting the literature search, we readthe abstracts and obtained the relevant articles. We also examined the referencesections of the relevant articles for other studies that should be included in the review.A total of 24 studies met inclusion criteria for this study as of December 15, 2008.

Results

The 24 studies addressed problems in eight areas: depression (eight studies), anxiety(six studies), unforgiveness (three studies), eating disorders (two studies), schizo-phrenia (one study), alcoholism (one study), anger (one study), and marital issues

48 Journal of Clinical Psychology, January 2010


(one study). One study addressed general psychological problems. R/S worldviewsinclude Christianity (10 studies), Islam (seven studies), Taoism (one study),Buddhism (one study), and a more generic spirituality (five studies). The resultsare organized first by efficacy status, and then by treatment (see Table 1). We havecalculated effect sizes when possible.

Efficacious Treatments

Two R/S therapies were deemed efficacious: Christian accommodative cognitivetherapy (CT) for depression and 12-step facilitation (TSF) for alcoholism.

Christian Accommodative CT for Depression. Christian accommodative CTgenerally retained the main features of the existing secular theory (i.e., Beck or Ellis)yet placed the therapy in a religious context. Techniques such as cognitiverestructuring and guided imagery were integrated with Biblical teaching andreligious imagery.

Evidence for efficacyThree studies (Pecheur & Edwards, 1984; Propst, 1980; Propst, Ostrom, Watkins,Dean, and Mashburn, 1992) compared Christian CT (i.e., Beck-based) fordepression with a control condition. Each study found evidence that participantsin Christian CT showed more improvement in depressive symptoms than didparticipants in the control condition. Two studies compared Christian CT (i.e., Ellis-based) for depression with an alternative treatment (Johnson, Devries, Ridley,Pettorini, & Peterson, 1994; Johnson & Ridley, 1992). These studies found evidencethat participants in Christian CT showed equivalent improvement in depressivesymptoms as did participants in the alternative treatment; however, the sample sizesof these studies were too small to make a determination about efficacy based on theequivalence of these treatments. Nevertheless, based on the three studies that foundparticipants in Christian CT outperformed participants in a control condition,Christian CT should be viewed as an efficacious treatment for depression.

Evidence for specificityFive studies (Johnson et al., 1994; Johnson & Ridley, 1992; Pecheur & Edwards,1984; Propst, 1980; Propst et al., 1992) compared Christian CT with secular CT. Nostudies found that participants in Christian CT improved more in depressivesymptoms than did participants in secular CT at posttest. One study (Propst) noted atrend ( po.10) for Christian CT to outperform secular CT at a 6-week follow-up.However, most of the data do not provide evidence for the specificity of ChristianCT for depression.

Follow-up resultsThe maintenance of treatment effects for Christian CT was explored in four studies(Johnson et al., 1994; Pecheur & Edwards, 1984; Propst, 1980; Propst et al., 1992). Inall studies, treatment gains from Christian CT were maintained at follow-up.

Clinical significanceThree studies (Johnson et al., 1994; Propst, 1980; Propst et al., 1992) reported dataon the clinical significance of treatment effects, that is, whether the treatmentsproduced meaningful changes in a person’s daily life. Two studies found that moreparticipants in Christian CT ended treatment in the non-depressed range of the BDI



Table

1EmpiricalStatusofReligiousandSpiritual(R/S)Therapies

Treatm

ent

Study

Participants/therapists

Treatm

ent

conditions

Posttest

results

Follow-up

results

Clinical

significance

Effectiveness

Efficacioustreatm

ents

Depression

ChristianCT

Johnsonet

al.

(1994)

29Christianadults

Scored15oraboveonBDI

2therapists

Each

therapistperform

edboth

conditions

1.CRET(n

513)

�8ind.

sessions

�1houreach

2.RET(n

516)

�8ind.sessions

�1houreach

BDI 1

52

BDI(3

mo.)

1&

2

maintained

gains

152

#depressed

rangeofBDI

atposttest

15

2

#meaningful

change

15

2

Johnsonand

Ridley(1992)

10Christianadults


1therapist

Therapistperform

edboth

conditions

1.CRET(n

55)

�6ind.sessions

�2sessions/wk.

�1houreach

2.RET(n

55)

�6ind.sessions

�2sessions/wk.

�1houreach

BDI 1

52

Ratingoftherapist

152

Pecheurand

Edwards(1984)

21Christiancollegestudents


Met

DSM-III

criteria

formajor

depressivedisorder

1therapist

Therapistperform

edboth

conditions

1.RCBM

(n57)

�8ind.sessions

�2sessions/wk.

�1houreach

2.SCBM

(n57)

�8ind.sessions

�2sessions/wk.

�1houreach

3.Control(n

57)

BDI 143(d

52.06)

152

BDI(1

mo.)

1&

2

maintained

gains

152



Propst

(1980)

44religiouscollegestudents


2therapists

Each

therapistperform

edboth

conditions

Therapists

werenotreligious

1.ReligiousIm

agery(n

59)

�8groupsessions

�2sessions/wk.

�1houreach

2.Non-religiousIm

agery

(n5

11)

�8groupsessions

�2sessions/wk.

�1houreach

3.Therapist

1Monitoring

(n5

13)

�8groupsessions

�2sessions/wk.

�1houreach

4.MonitoringOnly

(n5

11)

�Monitoreddailymood

BDI 1

52

53

54

MMPI-D

144

152

53

MMPI-D

(6

wk.)

142

143

144

(trend,

po.10)

#depressed

rangeofBDI

atposttest

142

144

153

Ratingoftherapist

152

53

14

4

Propst

etal.(1992)59Christianadults

Scored14oraboveonHRSD

Haddysphoricmoodand

3DSM-III

symptomsof

depression

10therapists

8therapists

perform

edboth

RCT

andNRCT

4therapistswerereligious,and4

werenotreligious

2therapists

perform

edPCT

1.RCT

(n519)

�18ind.sessions

�1houreach

2.NRCT

(n519)

�18ind.sessions

�1houreach

3.PCT(n

510)

�18ind.sessions

�1houreach

4.Control(n

511)

BDI 144(d

51.20)

152

53

BDI(3

mo.,

2yr.)

1,2,&

3

maintained

gains

152

53

#depressed

rangeofBDI

atposttest

144

#meaningful

change

14

4

152

53

Non-religiousand

religious

therapists

both

able

todo

religiousCT

Alcoholism

12-step

facilitation

Project

Match

ResearchGroup

(1997)

952outpatientadults

774aftercare

adults

Met

DSM-III-R

criteria

for

alcoholabuse

ordependence

80therapists

Each

therapistperform

edone

1.TSF

�12ind.sessions

�1session/w

k.

�1houreach

2.CBT

�12ind.sessions

PDA 1

52

53

DDD

152

53

Outpatient

PDA

(1yr.)

142

153

PDA

(3yrs.)

Satisfaction

152

53



TABLE

1.

Continued

Treatm

ent

Study


Treatm

ent

conditions

Posttest

results

Follow-up

results

Clinical

significance

Effectiveness

condition

Chosenbasedoncurrentwork

within

particulartherapy

�1session/w

k.

�1houreach

3.MET

�4ind.sessions

�1session/w

k.

�1houreach

142

15

3

DDD

(1yr.)

142

15

3

DDD

(3yrs.)

142

15

3

%CA

(1yr.)

142

143

%CA

(3yrs.)

142

143

Aftercare

PDA

(1yr.)

142

143

DDD

(1yr.)

15

253

%CA

(1yr.)

15

253



Efficacioustreatm

ents,combined

withmedication

Depression

Muslim

psychotherapy

Azhar&

Varm

a

(1995a)

30Muslim

outpatients

Met

DSM-IIIR

criteria

for

majordepression

Notherapistinform

ation

1.Religious(n

515)

�Supportivetherapy

�Antidepressant

medication

�Religioustherapy

2.Comparison(n

515)


�Antidepressant

medication

HRSD

1mo:142

(d5

1.70)

3mo:142

(d5

.81)

6mo:142

(d5

.75)

Azhar&

Varm

a

(1995b)

64Muslim

outpatients

Met

DSM-IIIR

criteria

for

dysthymic

disorder

Notherapistinform

ation

1.Religious(n

532)


�Antidepressant

medication

�Religioustherapy

2.Comparison(n

532)


�Antidepressant

medication

HRSD

1mo:142

(d5

.38)

3mo:142

(d5

.51)

6mo:1

52

Razaliet

al.(1998)100Muslim

outpatients

Met

DSM-IIIR

criteria

for

majordepressivedisorder

Notherapistinform

ation

1.Religious(n

552)


�Antidepressant

medication

�Religioustherapy

2.Comparison(n

548)


�Antidepressant

medication

HRSD

1mo:142

(d5

.70)

3mo:142

(d5

.56)

6.5

mo:1

52

Anxiety

Muslim

psychotherapy

Azharand

Varm

a(1994)

62Muslim

outpatients

Met

DSM-IIIR

criteria

for

generalizedanxiety

disorder

Notherapistinform

ation

1.Religious(n

531)


�Benzodiazepine

medication

�Religioustherapy

2.Comparison(n

531)

HARS

3mo:142

(d5

1.03)

6mo:1

52



TABLE

1.

Continued

Treatm

ent

Study


Treatm

ent

conditions

Posttest

results

Follow-up

results

Clinical

significance

Effectiveness


�Benzodia-

zepinemedication

Razaliet

al.

(1998)

103Muslim

outpatients

Met

DSM-IIIR

criteria

for

generalizedanxiety

disorder

2therapists

1.Religious(n

554)


�Benzodiazepine

medication

�Religioustherapy

2.Comparison(n

549)


�Benzodiazepine

medication

HARS

1mo:142

(d5

.67)

3mo:142

(d5

.55)

6.5

mo:1

52

Razaliet

al.

(2002)

165Muslim

outpatients

Met

DSM-IIIR

criteria

for

generalizedanxiety

disorder

Notherapistinform

ation

Religiouspatients

1.Religious(n

545)


�Benzodiazepine

medication

�Religioustherapy

2.Comparison(n

540)


�Benzodiazepine

medication

Non-religiouspatients

3.Religious(n

542)


�Benzodiazepine

medication

�Religioustherapy

4.Comparison(n

538)


�Benzodiazepine

medication

HARS

1mo:142

(d5

.64)

3mo:142

(d5

.61)

6.5

mo:1

52

1mo:3

54

3mo:3

54

6.5

mo:3

54



Possibly

efficacioustreatm

ents

Anxiety

ChristianDM

Carlsonet

al.

(1988)

36Christiancollegestudents

Noexperim

enterinform

ation

1.DM

(n512)

�6ind.sessions

�3sessions/wk.

�20min.each

2.PR

(n512)

�6ind.sessions

�3sessions/wk.

�20min.each

3.Control(n

512)

Muscle

Tension

142

Anxiety

142

143

Anxiety

TaoistCT

Zhanget

al.(2002)143Chinesepatients

Met

CCMD-2-R

criteria

for

generalizedanxiety

disorder

4therapists

Trained

inCTCT

1.CTCT(n

546)

�14ind.sessions

�1session/w

k.(1

mo.)

�1session/2

wks.

(5mos.)

�1houreach

2.BDZ(n

548)

�14ind.sessions

�1session/w

k.(1

mo.)

�1session/2

wks.

(5mos.)

�10minuteseach

�Benzodiazepine

medication

3.Combined

(n549)

�14ind.sessions

�1session/w

k.(1

mo.)

�1session/2

wks.

(5mos.)

�1houreach

�Benzodiazepine

medication

SCL-90

1mo:1o2

(d5

.77)

1mo:1o3

(d5

.54)

1mo:2

53

6mo:142

(d5

.86)

6mo:243

(d5

.88)

6mo:1

53

Unforgiveness

Christian

group

Ryeand

Pargament

(2002)

58Christianunder

graduate

females

Experiencedawrongdoingin

a

1.Religious(n

519)

�6groupsessions

�1session/w

k.

RFS 143(d

51.34)

RFS(6

wk.)

1&

2

maintained

Enjoyed

program

1o2(d

5.93)

8other

program



TABLE

1.

Continued

Treatm

ent

Study


Treatm

ent

conditions

Posttest

results

Follow-up

results

Clinical

significance

Effectiveness

romanticrelationship

3therapists

Each

therapistperform

edboth

conditions

Therapists

notinform

edof

hypotheses

Therapists

hadR/S

beliefs,but

werenotinvolved

inanRO

duringstudy

�1.5hours

each

2.Secular(n

520)

�6groupsessions

�1session/w

k.

�1.5hours

each

3.Control(n

519)

243(d

51.08)

152

gains

143

(d51.24)

243

(d5.67)

152

quality

questions

152

Ryeet

al.(2005)149divorced

adults

5therapists

Each

therapistperform

edboth

conditions

Therapists

notinform

edof

hypotheses

Therapists

said

spirituality

was

importantto

them

1.Religious(n

550)

�8groupsessions

�1session/w

k.

�1.5hours

each

2.Secular(n

549)

�8groupsessions

�1session/w

k.

�1.5hours

each

3.Control(n

550)

RFS;Growth

Rate

143

243

152

RFS 1&

2

maintained

gains

Unforgiveness

Spiritualgroup

Hart

and

Shapiro(2002)

61sober

adultmem

bersofAA

8therapists

Each

therapistperform

edone

condition

Mostworked

withaddiction,and

wererecoveredalcoholics

1.Spiritual(n

530)

�10groupsessions

�1session/2

wks.

�2hours

each

�10phonecalls

2.Secular(n

531)

�10groupsessions

�1session/2

wks.

�2hours

each

�10phonecalls

TRIM 142

TRIM 142



MaritalIssues

Christian

groupCBT

Combset

al.

(2000)

31Christiancouples

Notherapistinform

ation

1.ChristianCBT(n

515

couples)

�5groupsessions

�1session/w

k.

�2hours

each

2.Control(n

516couples)

DAS 142(d

5.90)

DAS(6

mo.)

1 maintained

treatm

ent

gains

General

psychological

problems

Christianlay

counseling

Toh&

Tan

(1997)

46Christianclients

18therapists

Worked

atchurch

1.LC

(n5

22)

�10ind.sessions

�1session/w

k.

�1houreach

2.Control(n

524)

BSI 142(d

5.71)

BSI(1

mo.)

1 maintained

treatm

ent

gains

Possibly

efficacioustreatm

ents,combined

withexistinginpatienttreatm

ent

EatingDisorders

Spiritualgroup

intervention

Richardset

al.

(2006)

122women

ininpatientclinic

Met

DSM-IV

criteria

for

AN,BN,orED-N

OS

3therapists

2therapists

each

perform

ed

spirituality

andcognitive

conditions

1therapistperform

edem

otional

support

condition

1.Spirituality

(n543)

�Groupsessions

�1session/w

k.

�1houreach

2.�Cognitive(n

535)

�Groupsessions

�1session/w

k.

�1houreach

3.Emotionalsupport

(n544)

�Groupsessions

�1session/w

k.

�1houreach

EAT 142(d

5.68)

153

Anger BuddhistCBT

VannoyandHoyt

(2004)

31incarceratedadultmales

1therapist

Experience

withmeditation

training

1.BuddhistCBT(n

516)

�12groupsessions

�1session/w

k.

�1.5hours

each

2.Control(n

515)

STAXI-2

142(d

5.76)

Noevidence

forefficacy

Anxiety

Spiritualgroup

CBT

Nohr(2001)

67undergraduate

students

1therapist

Therapistperform

edboth

conditions

1.SCBT(n

541)

�4groupsessions

�1session/w

k.

�1.5hours

each

SCL-90-R

1&

2im

proved

from

pretest

to

SCL-90-R

(1

mo.)

1&

2



TABLE

1.

Continued

Treatm

ent

Study


Treatm

ent

conditions

Posttest

results

Follow-up

results

Clinical

significance

Effectiveness

2.CBT(n

526)

�4weekly

sessions

�1session/w

k.

�1.5hours

each

3.Control(n

514)

posttest.

152

53

maintained

gains

Schizophrenia

Muslim

accommodative

CBT

Wahass

and

Kent(1997)

6male

Muslim

hospitalpatients

Met

ICD-10criteria

for

schizophrenia

Notherapistinform

ation

1.Muslim

CBT(n

53)

�25ind.sessions

�3sessions/wk.

�1houreach

2.Control(n

53)

SAHI

1:2of3patients

improved

2:0of3patients

improved

SAHI(3

mo.)

1:Patients

regressed

some

EatingDisorders

ChristianCBT

Tonkin

(2005)

18female

adults

Met

criteria

forBN

or

BED

basedonEating

DisordersExamination

1therapist

Therapistperform

edboth

conditinos

Christian

1.ChristianCBT(n

59)

�16groupsessions

�1session/w

k.

�1.5hours

each

2.SecularCBT(n

59)

�16groupsessions

�1session/w

k.

�1.5hours

each

WeightLoss

152

Calories

152

EDI-2

152

Exercise

152

Note.

CT

5cognitive

therapy;

CRET

5Christian

rational-em

otive

therapy;

RET

5rational-em

otive

therapy;

RCBM

5religious

cognitive

behavior

modification;

SCBM

5secularcognitivebehaviormodification;RCT

5religiouscognitivebehavioraltherapy;NRCT

5standard

cognitivebehavioraltherapy;PCT

5pastoralcounseling

treatm

ent;TSF

5tw

elvestep

facilitation;CBT

5cognitivebehavioraltherapy;MET

5motivationalenhancementtherapy;PDA

5percentdaysabstinent;DDD

5drinksper

drinking

day;%

CA

5percentcompletely

abstinentin

last

3mo.;

DM

5devotionalmeditation;PR

5progressiverelaxation;CTCT

5ChineseTaoistcognitivetherapy;

BDZ

5benzodiazepinemedication;RO

5religiousorganization;LC

5laycounseling;BDI

5BeckDepressionInventory

(Becket

al.,1961);HRSD

5HamiltonRatingScalefor

Depression

(Hamilton,1967);

MMPI-D

5Depression

subscale

of

the

MMPI

(Overall

etal.,1975);

HARS

5Hamilton

Anxiety

Rating

Scale

(Hamilton,1959);

SCL-90

5Symptom

Checklist

(Derogatis,

1977,1992);RFS

5RyeForgivenessScale

(Ryeet

al.,2001);TRIM

5TransgressionRelatedInterpersonalMotivationsInventory

(McC

ulloughet

al.,1998);DAS

5DyadicAdjustmentScale(Spanier,1976);BSI

5Brief

Symptom

Checklist(D

erogatis&

Spencer,1982);EAT

5EatingAttitudes

Test(G

arner

&Garfinkel,1979);

STAXI-2

5State

Trait

Anger

Inventory

(Spielberger,1988);

SAHI

5Structured

Auditory

Hallucinations

Interview

(Kent

&Wahass,1996);

DSM

5Diagnostic

andstatisticalmanualofmentaldisorders;CCMD-2-R

5Chineseclassificationofmentaldisorders;IC

D-10

5Internationalclassificationofdiseases.



than did participants in a control condition (Propst; Propst et al.). One study foundthat more participants in Christian CT ended treatment in the non-depressed rangeof the BDI than did participants in secular CT (Propst), whereas another studyfound equal rates of non-depressed individuals in Christian accommodative CT andsecular CT (Johnson et al.). Using statistical measures of meaningful change(Jacobson, Follette, & Revenstorf, 1984; Jacobson & Traux, 1991), one study foundthat more participants in Christian accommodative CT showed meaningful changethan did participants in a control condition (Propst et al.), and one study showedequal numbers of participants exhibiting meaningful change in Christian accom-modative CT and secular CT (Johnson et al.).

EffectivenessTwo studies asked participants to rate the effectiveness of the therapist (Johnson &Ridley, 1992; Propst, 1980). Ratings of the therapist in Christian CT were higherthan ratings in a control condition (Propst). There were no differences betweenratings of the therapist in Christian CT and secular CT (Johnson & Ridley; Propst).Propst et al. (1992) had both religious and nonreligious therapists conduct bothChristian CT and secular CT. Nonreligious therapists were effective at deliveringChristian accommodative CT, suggesting that nonreligious therapists may be able toincorporate religion into therapy effectively even when the religious techniques donot align with the therapist’s own worldview.

12-Step Facilitation for Alcoholism. Twelve-step facilitation encouraged clientsto view alcoholism as a spiritual and medical disease (Project Match ResearchGroup, 1997). Its goals were to foster acceptance of the disease of alcoholism,develop a commitment to attend Alcoholics Anonymous, and begin workingthrough the 12 steps.

Evidence for efficacyOne study compared 12-step facilitation with two alternative treatments foralcoholism: cognitive behavioral coping skills therapy and motivational enhance-ment therapy (Project Match Research Group, 1997). Participants were recruitedfrom two settings: outpatient (recruited from community or outpatient treatmentcenters) and aftercare (recruited following completion of inpatient or intensive dayhospital treatment). Participants in all conditions improved from pretest to postteston percent days abstinent (PDA; a measure of drinking frequency) and number ofdrinks per drinking day (DDD; a measure of drinking severity). Twelve-stepfacilitation was equivalent to a treatment already established in efficacy.Furthermore, although this was only one study, it comprised clinical trials thatoccurred at several different sites with large sample sizes. Thus, based on thismultisite clinical trial, 12-step facilitation should be viewed as an efficacioustreatment for alcoholism.

Evidence for specificityAt posttest, participants in 12-step facilitation reported equivalent improvement indrinking frequency and severity as did participants in the other treatment conditions.However, at follow-up participants in 12-step facilitation showed more improvementin drinking frequency than did participants in the other treatment conditions(Project Match Research Group, 1998). Also, at follow-up a greater percentage ofparticipants in 12-step facilitation reported not drinking at all in the past 3 months



than did participants in the other treatment conditions. Thus, there is some evidencefor the specificity of 12-step facilitation for the treatment of alcoholism.

Follow-up resultsThe maintenance of treatment effects was evaluated at 3, 6, 9, and 12 months(Project Match Research Group, 1997) and at a 3-year follow-up (Project MatchResearch Group, 1998). Participants in 12-step facilitation maintained theirtreatment gains at each follow-up.

Efficacious Treatments, Combined With Medication

Two R/S therapies were deemed efficacious when used in the context of medication:Muslim psychotherapy for depression and Muslim psychotherapy for anxiety.

Muslim Psychotherapy for Depression. Muslim psychotherapy for depressioncomprised discussions of religious issues that pertained to participants (e.g., readingverses from the Koran, using the Prophet as a model for changing one’s lifestyle, andencouraging clients to pray). In the studies that evaluated Muslim psychotherapy fordepression, this therapy was given in addition to weekly supportive psychotherapyand mild doses of antidepressant medication.

Evidence for efficacyThree studies compared Muslim psychotherapy for depression with a comparisoncondition (Azhar & Varma, 1995a,b; Razali, Hasanah, Aminah, & Subramaniam,1998). In two studies with sufficient power to detect medium differences, participantsin the Muslim psychotherapy condition showed equivalent improvement indepressive symptoms as did participants in the comparison condition (Azhar &Varma, 1995b; Razali et al., 1998). In one study, participants in Muslimpsychotherapy condition showed more improvement in depressive symptoms thandid participants in the comparison condition (Azhar & Varma, 1995a). Thus, basedon these three studies, Muslim psychotherapy for depression should be viewed as anefficacious treatment when combined with medication.

Evidence for specificityAll three studies found that participants in the religious condition showed moreimprovement in depressive symptoms than did participants in the control conditionat 1 month and 3 months. However, only one study found that participants in thereligious condition showed more improvement in depressive symptoms than didparticipants in the control condition at the end of the study (6 months; Azhar &Varma, 1995a).These studies are somewhat difficult to interpret. The addition of the Muslim

psychotherapy improved outcomes in depressive symptoms in the early part oftreatment. This provides some evidence for the specificity of Muslim psychotherapyfor depression. However, the Muslim psychotherapy was given in addition to weeklysupportive psychotherapy. Participants in the religious condition had an additionalsession of weekly therapy than did participants in the control condition. It is difficultto distinguish whether the improvement of participants in the religious condition isspecifically due to the religious therapy, or whether it is a general dose-responseeffect as a result of having more therapy per week. Thus, there is limited evidence forthe specificity of Muslim psychotherapy for depression.



Muslim Psychotherapy for Anxiety. Similar to Muslim psychotherapy fordepression, Muslim psychotherapy for anxiety comprised discussions of religiousissues that pertained to participants (e.g., reading verses of the Koran, praying as aform of relaxation). Also, this therapy was given in addition to weekly supportivepsychotherapy and benzodiazepine medication.

Evidence for efficacyThree studies compared Muslim psychotherapy for anxiety with a comparisoncondition (Azhar, Varma, & Dharap, 1994; Razali et al., 1998; Razali, Aminah, &Khan, 2002). All studies had sufficient power to detect medium differences.Participants in the Muslim psychotherapy condition showed equivalent improve-ment in anxiety symptoms as did participants in the comparison condition. Based onthese studies, Muslim psychotherapy for anxiety should be viewed as an efficacioustreatment for anxiety when combined with medication.

Evidence for specificityTwo studies found that participants in the religious condition showed moreimprovement in anxiety symptoms than did participants in the control condition at 1month (Razali et al., 1998, 2002; the Azhar et al., 1994 study did not assess anxiety at1 month). All three studies found that participants in the religious condition showedmore improvement in anxiety symptoms than did participants in the controlcondition at 3 months. However, in all three studies, there were no differences inanxiety symptoms at the end of the study (6–6.5 months). There are similardifficulties when interpreting these studies as in the Muslim studies for depression.Participants in the religious condition were given additional therapy; thus, it isdifficult to distinguish the effects of the religious therapy from the additional therapyin general. Based on these studies, there is limited evidence for the specificity ofMuslim psychotherapy for anxiety.

Evidence for matchingRazali et al. (2002) assessed the participants’ level of religiosity. They hypothesizedthat religious therapy would be helpful for highly devout Muslims, but it would notbe helpful for those who were not very religious. For participants who were religious,those in the religious condition showed more improvement in anxiety symptomsthan did participants in the control condition at 1 month and 3 months (althoughthere was no difference at the end of the study, 6.5 months). However, forparticipants who were not religious, there were no differences in anxiety symptomsbetween the religious and control condition at any point in the study (1, 3, or 6.5months). This provides some evidence that R/S therapies may improve outcomes forhighly religious clients, but not for clients who are not highly religious.

Possibly Efficacious Treatments

Several R/S therapies were deemed possibly efficacious, either because only one studysupported their efficacy or because all the studies supporting their efficacy wereconducted by the same lab. Possibly efficacious R/S therapies included Christiandevotional meditation for anxiety, Taoist CT for anxiety, Christian accommodativegroup treatment for unforgiveness, spiritual group treatment for unforgiveness,Christian accommodative group CBT for marital discord, and Christian laycounseling for general psychological problems.



Christian Devotional Meditation for Anxiety. Relaxation has long been viewed asan important psychological intervention (Jacobson, 1938). Studies have found thatpractices such as meditation can often have similar effects as muscle relaxation(Raskin, Bali, & Peeke, 1980). Christian devotional meditation has long beenemphasized in Christianity and generally involves practices or disciplines of prayeror quiet reflection on certain passages of Scripture (Carlson, Bacaseta, & Simanton,1988).

Evidence for efficacy and specificityCarlson et al. (1988) compared Christian devotional meditation with a controlcondition and a progressive muscle relaxation condition. During the practicesessions, participants in the devotional meditation condition had lower muscletension than did participants in the progressive relaxation condition. Participants inthe control condition had no practice sessions and were not measured on muscletension. After treatment, participants in the devotional meditation conditionreported less anxiety than did participants in the progressive relaxation and controlconditions. Christian devotional meditation should be viewed as a possiblyefficacious treatment for anxiety. There is also some evidence for the specificity ofthis treatment.

Taoist CT for Anxiety. Taoist CT shares broad principles with secular CT, yet itis based in the philosophy of Taoism, which encourages one to conform to naturallaws, to let go of excessive control, and to flexibly allow one’s personality to develop(Zhang et al., 2002). The goal of Taoist CT is to regulate negative affect, correctmaladaptive behavior, and change modes of thinking and coping (Zhang et al.).

Evidence for efficacy and specificityZhang et al. (2002) compared Chinese Taoist CT with a benzodiazepine medicationcondition and a combined therapy medication condition for generalized anxietydisorder. At 1 month, participants in the Chinese Taoist CT condition showed lessimprovement in anxiety symptoms than did participants in the other conditions.However, by the end of treatment, participants in the Chinese Taoist CT conditionshowed more improvement in anxiety symptoms than did participants in themedication condition, and equivalent improvement as did participants in thecombined condition. Chinese Taoist CT should be viewed as a possibly efficacioustreatment for anxiety. There is also evidence for the specificity of this treatment.

Christian Accommodative Group Treatment for Unforgiveness. Christianaccommodative group treatment for unforgiveness was based on the REACHmodel of forgiveness (Worthington, 1998), which involves five steps: Recall the hurt,Empathize with the one who hurt you, Altruistic gift of forgiveness, Commitment toforgive, and Holding onto forgiveness. For the Christian treatment, participantswere encouraged to (a) draw on their religious beliefs while working towardforgiveness, (b) draw on religious sources of support when forgiving, and (c) useprayer and Scripture to help with the forgiveness process.

Evidence for efficacyTwo studies from the same lab compared Christian accommodative group treatmentwith a secular group treatment and a control condition (Rye & Pargament, 2002;Rye et al., 2005). Both studies found evidence that participants in the Christiancondition showed more improvement in forgiveness than did participants in the



control condition, and equivalent improvement in forgiveness as did participants inthe secular condition. Based on these two studies from the same laboratory,Christian accommodative forgiveness interventions should be viewed as a possiblyefficacious treatment for unforgiveness.

Evidence for specificityIn both studies, participants in the Christian condition showed no moreimprovement in forgiveness than did participants in the secular condition. Thus,there is no evidence for the specificity of Christian accommodative group treatmentfor unforgiveness.

Follow-up resultsBoth of the above studies evaluated the maintenance of treatment effects at a 6-weekfollow up. In both studies, both treatment conditions had maintained their treatmentgains.

Evidence for effectivenessRye and Pargament (2002) asked participants in both treatment conditions to ratethe program on several dimensions (e.g., enjoyment of program, willingness torecommend the program to a friend, usefulness of homework assignments, relevanceof program content, group leader competence). Although participants in bothconditions rated the program favorably, participants in the secular conditionreported that they enjoyed the program more than did participants in the Christiancondition.

Spiritual Group Treatment for Unforgiveness. Spiritual forgiveness grouptreatment for unforgiveness was a 12-step type program that was adapted to focuson forgiveness issues (Hart & Shapiro, 2002). The intervention focused on reducingone’s addiction to grudges, guilt, and shame. The intervention led participantsthrough a ‘‘spiritual solution’’ to the problem of powerlessness over anger andsuggested that reliance on a higher power was required to experience release from thebondage of anger.

Evidence for efficacy and specificityHart and Shapiro (2002) compared spiritual group treatment with a secular grouptreatment. Participants in the spiritual condition increased their forgiveness morethan did participants in the secular condition. Spiritual group treatment should beviewed as a possibly efficacious treatment for unforgiveness. There is also evidencefor the specificity of this treatment.

Follow-up resultsThe maintenance of treatment effects were tested at a four-month follow-up.Participants in both the spiritual and secular conditions maintained their treatmentgains (Hart & Shapiro, 2002). There was a trend for participants in the spiritualcondition to outperform participants in the secular condition on forgiveness.

Christian Group CBT for Marital Issues. Christian group CBT for maritalissues taught communication skills, cognitive reframing, conflict resolution skills,behavioral exchange, and relationship enhancement (Halter, 1988). Christiantheological principles and Scripture were explicitly integrated and discussedthroughout the program.



Evidence for efficacyCombs, Bufford, Campbell, and Halter (2000) compared Christian group CBT witha control condition. Participants in the Christian group CBT condition increasedmarital satisfaction more than did participants in the control condition. Christiangroup CBT should be viewed as a possibly efficacious treatment for marital issues.

Follow-up resultsThe maintenance of treatment effects was evaluated at six months (Combs et al.,2000). Participants in the Christian group CBT condition maintained their treatmentgains at follow-up.

Christian Lay Counseling for General Psychological Problems. Christian church-based lay counseling involved religious counseling offered by paraprofessionals. Laycounselors were trained in counseling skills in the context of time-limited therapy(Mann & Goldman, 1982).

Evidence for efficacyOne study compared Christian lay counseling with a control condition (Toh & Tan,1997). Participants in the lay counseling condition showed more improvement ingeneral psychological symptoms than did participants in the control condition.Christian lay counseling should be viewed as a possibly efficacious treatment forgeneral psychological problems.

Follow-up resultsThe maintenance of treatment effects was evaluated at a 1-month follow-up (Toh &Tan, 1997). Participants in the lay counseling condition maintained their treatmentgains at follow-up.

Evidence for effectivenessBoth the lay counselors and clients provided feedback about the counseling sessionsvia a post-counseling questionnaire. On average clients evaluated the counselingexperience as ‘‘very good.’’ Lay counselors rated their own experience from ‘‘good’’to ‘‘very good.’’

Efficacious Treatments, Combined With Existing Inpatient Treatment

Two R/S therapies were deemed possibly efficacious when used in the context ofexisting inpatient treatment: spiritual group therapy for eating disorders andBuddhist accommodative CT for anger.

Spiritual Group Therapy for Eating Disorders. Spiritual group therapy for eatingdisorders involved having participants read the self-help workbook SpiritualRenewal: A Journey of Faith and Healing (Richards, Hardman, & Berrett, 2000).The book comprises non-denominational readings that are consistent with a Judeo-Christian tradition. Readings address topics such as spiritual identity, grace,forgiveness, repentance, faith, prayer, and meditation. Participants met in a group todiscuss issues and complete exercises pertaining to the readings.

Evidence for efficacy and specificityRichards, Berrett, Hardman, and Eggett (2006) compared spiritual group therapywith two alternative treatments: a cognitive group therapy and an emotional support



group. Participants lived in a private inpatient facility for women with eatingdisorders. The treatment supplemented the regular inpatient treatment program,which comprised individual psychotherapy, group psychotherapy, experiential andexpressive activities, family counseling, nutritional counseling, and a 12-step group.Participants in spiritual group therapy improved more in eating disorder behaviorthan did participants in cognitive group therapy, and equally to participants in theemotional support group. Spiritual group therapy should be viewed as a possiblyefficacious treatment for eating disorders in the context of an inpatient treatmentprogram. There is also evidence for the specificity of this treatment in this context.

Buddhist Accommodative CBT for Anger. Buddhist CBT for anger involvedintegrating cognitive behavioral treatments for anger with Buddhist principles andmeditation practices (Vannoy & Hoyt, 2004). Cognitive behavioral treatments foranger teach strategies to regulate anger, and promote understanding possibleantecedents and consequences of anger. Buddhist teachings consider anger to be aform of suffering. Meditation is used to reduce anger and develop patience,compassion, and kindness.

Evidence for efficacyVannoy and Hoyt (2004) compared Buddhist accommodative CBT with a controlcondition. Participants were adult males incarcerated in a low-security prison.Participants in the Buddhist CBT condition reduced their anger more than didparticipants in the control condition. Buddhist accommodative CBT should beviewed as a possibly efficacious treatment in the context of a prison setting.

No Evidence for Efficacy. Three R/S therapies had no evidence for their efficacy:spiritual group CBT for anxiety, Muslim accommodative CBT for schizophrenia,and Christian accommodative CBT for eating disorders.

Spiritual Group CT for Anxiety. Spiritual group CBT for anxiety was based on aCBT model (Beck, 1984). Spirituality was incorporated, for example, as the therapistworked with clients to (a) refute irrational beliefs with spiritual truths, (b) findmeaning and growth from difficult events, and (c) imagine a comforting spiritualfigure in guided imagery.

Evidence for efficacy and specificityNohr (2001) compared spiritual group CBT with a secular group CBT and a controlcondition. Both treatment conditions improved from pretest to posttest. However,participants in spiritual group CBT did not report more improvement inpsychological symptoms than did participants in the control condition. Thus, thereis not enough evidence to support the efficacy of spiritual group CBT for anxiety.Participants in the spiritual group CBT condition also did not show moreimprovement in psychological symptoms than did participants in the secular groupCBT condition. Thus, there is no evidence for the specificity of spiritual group CBTfor anxiety.

Follow-up resultsThe maintenance of treatment gains were tested at a 1 month follow-up (Nohr,2001). Gains were maintained for both treatment conditions. This finding should beviewed cautiously, however, because only 25% of the participants who completedpretest and posttest measures returned to complete the follow-up measures.



Muslim Accommodative CBT for Schizophrenia. Muslim accommodative CBTfor schizophrenia involved CBT that integrated religious beliefs and practices withcoping strategies for dealing with auditory hallucinations (e.g., encouraging clientsto follow Islamic prayer patterns, read the Koran, listen to Islamic guidance throughaudio-cassettes, and evaluate the content of the voices in light of Islamic doctrine).This treatment was given in addition to psychotropic medication.

Evidence for efficacyWahass and Kent (1997) compared Muslim accommodative CBT with a controlcondition. Participants in both conditions continued their medication for the durationof the study. Two of the three participants in the Muslim-accommodative CBTcondition improved on the frequency of their auditory hallucinations. None of thethree participants in the control condition improved. However, the authors did notdirectly compare the two conditions. This study showed that Muslim CBT, whencombined with medication, may have beneficial effects on schizophrenia. However,there is not enough evidence to support the efficacy of Muslim accommodative CBTfor schizophrenia. Furthermore, participants in the Muslim accommodative CBTcondition did regress at 3-month follow-up.

Christian Accommodative Group CBT for Eating Disorders. Christianaccommodative group CBT for eating disorders discussed weight managementstrategies such as nutrition and exercise and cognitive behavioral approaches to stopthe cycle of eating disordered behavior. Eating disorder issues were discussed from aChristian perspective, including body image, social pressures, self-esteem,depression, viewing the body as a temple, and family influences (Tonkin, 2005).

Evidence for efficacy and specificityTonkin (2005) compared Christian accommodative group CBT with a secular groupCBT treatment of eating disorders. Overall, participants lost weight, decreasedcalorie consumption, increased exercise, and decreased eating disorder behaviorfrom pretest to posttest. However, there was no difference on any of these variablesbetween treatment conditions. Although the improvement of participants in theChristian condition was equivalent to the secular condition, the sample sizes in thisstudy were too small to make a determination about efficacy based on theequivalence of these treatments. There is also no evidence for the specificity ofChristian accommodative CBT for eating disorders.

Discussion

The present review evaluated the efficacy status of R/S therapies using the criteria ofChambless and Hollon (1998). Several important findings should be noted. First,regarding the basic question of efficacy (i.e., does this therapy work?) the generalfindings for R/S therapies are positive. Several different types of R/S therapies werehelpful for clients with different types of psychological problems. Gains made fromR/S therapies were generally maintained at follow-up. Although only two R/Stherapies met the strict criteria for efficacy as outlined by Chambless and Hollon(1998), this is not because the research evidence shows that the R/S therapies are notworking. Rather, it is due to the relatively small number of replicated, high quality,controlled outcome studies addressing specific psychological problems. Weencourage caution in interpreting this positive finding. The fundamental questionof efficacy asks whether the treatment works, irrespective of the reason why it works.



Most R/S therapies in the present review incorporated R/S into an establishedsecular therapy. Reporting that R/S therapies have evidence for efficacy simplymeans that the therapy works as a whole; it does not necessarily provide evidence forthe efficacy of the specific R/S components.Clinicians who wish to incorporate R/S into therapy should be confident that these

therapies have evidence supporting their efficacy, at least for the therapies in thepresent review. However, the body of literature on R/S therapies is small, and thereare many R/S therapies that have no evidence supporting their efficacy. For theclinician who wishes to incorporate R/S into a therapy for which there is currently noempirical research, we note the majority of research in this area has found thatintegrating R/S into an established secular therapy has produced an R/S therapy thatis at least as efficacious as the existing secular therapy. This is understandable, asmost R/S accommodative therapies retain the main factors of the established seculartherapy. We have no recommendations for the use of R/S therapies that have noempirical support and do not incorporate an existing secular therapy that hasestablished empirical support. More research on such therapies is needed.In addition to evaluating the efficacy of R/S therapies, the present review

evaluated the specificity of R/S therapies (i.e., does this therapy work better than analternative treatment?). Although no R/S therapies met the strict criteria forspecificity as outlined by Chambless and Hollon (1998), there is some evidence forspecificity among R/S therapies. However, these studies either (a) have not beenreplicated (e.g., Christian devotional meditation for anxiety, Taoist CT for anxiety)or (b) have methodological problems that make it difficult to make strongconclusions about the specificity of R/S therapies (e.g., Muslim psychotherapy fordepression and anxiety). There are also several comparative studies that have shownequivalent findings for R/S therapies and secular therapies (e.g., Christian CT fordepression). Thus, although there is modest evidence that R/S therapies canoutperform alternative treatments, the evidence is not strong enough to makerecommendations for R/S therapies over alternative treatments for specificpsychological problems. In fact, in many cases, the scenario that develops is asfollows. An investigator modifies a secular treatment by including R/S elements andtests the modified version versus the secular version, but no differences are found.The real question that arises in such a case is this: Did the modification actually doanything at all? In future generations of R/S research, researchers need to evaluatewhat, if any, benefits accrue to modifying a known effective treatment. The burdenof proof is on the researcher to show that modification makes some positivedifference.One relevant problem that occurs when evaluating the specificity of therapies is

researcher therapy allegiance, which refers to the finding that a researcher’spreference for a specific therapy may improve the outcome of that therapy whencompared with alternative treatments (Luborsky et al., 1999; Robinson, Berman, &Neimeyer, 1990). It is possible that a researcher who spends the time and effort toconduct an outcome study on an R/S therapy may have an allegiance to that type oftherapy and R/S perspective. Thus, it is possible that some of the positive findingsfavoring R/S therapies could be, in part, an artifact of researcher allegiance. Theseeffects may be limited in studies that include researchers that represent a mix oftherapy allegiances (e.g., Project Match Research Group, 1997) or that use therapistswith a mix of R/S worldviews (e.g., Propst et al., 1992). Nevertheless, interpretationof the actual effects requires caution because, in many cases, allegiance effects maybe confounded with the outcomes.



Many psychologists who study R/S therapy advocate a matching hypothesis,noting the importance of tailoring therapy to certain important aspects of clients(Norcross, 2002; Wade et al., 2007; Worthington & Sandage, 2002). Almost all of thestudies in the present review used participants who self-identified with the R/S of thetherapy. However, all R/S individuals are not alike in their beliefs or practice of R/S.Worthington (1988) has suggested that highly religious individuals view their worldthrough a religious lens, which affects their values. Perhaps the matching hypothesismust become more precise to allow for variation in religious commitment. One studyin the present review found that incorporating R/S into therapy was helpfulfor highly religious individuals but not for those who were not highly religious(Razali et al., 2002). This finding supports previous research that has found R/Stherapy to be helpful for individuals who are highly religious (Wade et al., 2007).There are limitations to the present review. In addition to the small number of

studies, the quality of the religious and spiritual outcome studies was an issue.Several studies were excluded from the present review because they either (a) did nothave a control or comparison group or (b) did not randomize participants tocondition. Such non-experimental or quasi-experimental designs do not allowresearchers to draw strong conclusions because factors other than the treatment mayinfluence outcomes (e.g., selection bias). Furthermore, for some studies included inthe present review, it was difficult to make strong conclusions about the resultsbecause they were tested only in combination with another treatment or set oftreatments.There are also issues with internal validity and the methods by which treatment

outcomes were evaluated. Although it is almost impossible to ensure that therapistsare masked to condition because therapists are generally delivering a specificmanualized treatment, only two studies in the present review noted that therapistswere masked to the study hypotheses (Rye & Pargament, 2002; Rye et al., 2005).Indeed, the fact that some of the therapists in the studies were also the investigatorsraises even more questions of researcher therapy allegiance. Sample sizes weregenerally small, and many studies suffered from low power. In addition, the degreeof clinically significant change has rarely been assessed. Furthermore, outcomesgenerally measured the overall effect of a treatment on psychological symptoms.Analyses of effective components of treatments have been rare.Based on the findings of the present review, as well as the weaknesses noted in the

studies reviewed, we believe that an aggressive research agenda is warranted. First,the volume of outcome research examining R/S therapies should be increased. Thecurrent review of the literature indicates that R/S therapies are helpful for treatingsome areas of psychopathology; however, studies in several areas have yet to bereplicated. Second, the methodological rigor of the studies examining R/S therapiesmust be increased. Recommendations for researchers include (a) consistent use ofcontrol groups and randomization to treatment, (b) inclusion of a variety of types ofresearchers and therapists to reduce researcher therapy allegiance effects, (c)assurance that therapists are masked to study hypotheses, (d) increase in sample sizeand power, and (e) focus on clinically significant change. Third, future researchshould evaluate the matching hypothesis with more precision to examine whetherR/S therapies are more effective for those with high levels of religious commitment.Clinicians who use or are thinking about using R/S therapies should be confident

that evidence-based research supports the use of some R/S therapies. The researchfindings suggest that R/S therapies may work for treating psychological problems forR/S clients, and these therapies may work as well and, in a few cases, better than



comparable secular therapies. However, there is currently not enough empiricalevidence to suggest that R/S therapies are superior in efficacy than comparablesecular therapies. Thus, the decision to use an R/S therapy may be an issue of (a)client preference and (b) therapist comfort.

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empirically supported religious and spiritual therapies

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