Adapted excerpt from “Cognitive Behavioral Therapy for Christians with Depression:  A Practical, Tool-Based Primer” book in preparation. Buy your copy here: https://www.templetonpress.org/book/cognitive-behavioral-therapy

Does Religion Belong in Psychotherapy?

This question is posed by a lot of mental health practitioners. Here’s the short answer: If religion is important to our clients, religion will be part of psychotherapy whether we discuss it or not.

A religious identity and worldview are integral aspects of how religious clients think about, experience, respond to, and take action upon their world. This means there is a good chance their religious faith is a lens through which they view their experience of mental health problems and recovery. If we don’t discuss our clients’ religious beliefs and worldview, we may be missing vital information and a significant way of improving their psychological well-being.

Did you know research says the majority of clients want their therapists to discuss their religious beliefs and practices with them? In several studies, between 53% and 77% of clients reported wanting to have a discussion about religious or spiritual issues (Baetz et al., 2004; Rose et al., 2001), and 72% preferred to see a practitioner who respected and integrated their religious beliefs into therapy (AACP, 2000). In fact, the more religious a client is, the more likely she or he will want religion to play a role in therapy (Morrow, Worthington, & McCullough, 1993). Other research shows that some clients think therapists who integrate religion and spirituality into treatment are more competent than those who do not (McCullough & Worthington, 1995).

The Challenge in Clinical Practice

The challenge is that although the majority of therapists believe religion can be helpful to their clients (Delaney, Miller, & Bisono, 2007), many do not feel comfortable engaging in these issues because of their lack of familiarity with religion (Hathaway, Scott, & Garver, 2004). This is in part because a majority of doctoral programs and pre-doctoral internships do not provide clinical training in religious and spiritual issues (Vogel et al., 2013). It also does not help that psychologists and psychiatrists are traditionally less religious than the population they serve (Baetz et al., 2004; Delaney, Miller, & Bisono, 2007; Rosmarin et al., 2013). Not surprisingly, therapists with lower levels of personal religious or spiritual involvement are less comfortable assessing and addressing these issues in treatment and have less favorable attitudes toward religion (Rosmarin et al., 2013).

This means that a potentially healing resource for our clients often goes unnoticed and untapped. So, the question may not really be “Does religion belong?,” but rather, “How can we help our religious clients engage with and use their faith as a healing resource in psychotherapy?”

How to Address this Practice Challenge

To answer this question, we first need to know the benefits of addressing our clients’ faith in psychotherapy. Then, we need an organizing therapeutic approach, a set of practical tools to enable us to effectively integrate religion into treatment, and training to enable clinicians to use the approach. Indeed, with training in this area, therapists report feeling more comfortable and having more favorable attitudes toward religion (Rosmarin et al., 2013). Religiously-integrated CBT (RCBT) is one therapeutic approach with practical tools shown to be effective not only in reducing depression, but also in improving positive outcomes (e.g., gratitude, altruism, purpose in life) among religious clients (Koenig et al., 2015; Koenig et al., 2014). The specifics of RCBT are discussed in greater detail later in this article.

This is Therapy, Why Do I Need to Know about Religion?

Therapists need to know about religion for a number of reasons. First, America is a religious nation. National polls reveal that 93% of Americans believe in God or a higher power and 77% consider themselves to be religious (Kosmin & Keysar, 2009). Thus, the chances are excellent that therapists will treat, and have already treated, religious clients who are dealing with mental health issues.

Second, a large body of scientific work conducted by researchers worldwide has revealed a relation between religion and mental health. Take depression for example. In general, the more religious individuals are, the less likely they are to be depressed; and, if they do become depressed, they tend to recover more quickly (Bonelli et al., 2012). This finding may be because religion can help people cope with stress, buffer the effects of challenging life events, provide social support, and offer a framework for meaning and purpose, particularly for circumstances that seem senseless and beyond our control (Koenig et al., 2012).

Of course, religious individuals are not exempt from depression and other mental health problems. Religious individuals can also experience spiritual struggles, including problems in their relationship with God and with members of their religious community, all of which can worsen psychiatric symptoms (Pirutinsky et al., 2011).

Third, we need to know about religion because our ethical practice codes mandate it. The American Psychological Association’s ethical code states that religion is a domain of diversity that requires clinical competence (APA, 2002). These guidelines suggest that respecting clients’ religion requires more than just being aware that they are religious. We need to be intentional about knowing how our clients’ religion impacts how they view their world and function in it, as well as how it impacts their experience of and recovery from mental illness. Just like with other domains of diversity, we need ongoing training to achieve competency in this area.

Does Talking about Religious Beliefs and Practices in Therapy Actually Help Alleviate Mental Health Problems?

Over the last two decades, over 50 studies have been conducted to test the effectiveness of therapies that integrate clients’ religious and spiritual beliefs. In these studies, various forms of psychotherapy were modified to include religious and spiritual themes, discussions, imagery, sacred texts and, in some cases, prayer. Although the studies vary in their design and rigor, overall, the results suggest that talking about clients’ religious beliefs and practices during treatment helps to reduce symptoms of emotional distress. The majority of empirical studies have demonstrated that spiritually-integrated therapies are at least as effective, if not more effective, in reducing depression and anxiety than is traditional, non-religious therapy for religious clients (Anderson et al., 2015; Azhar & Varma, 1995; Azhar, Varma, & Dharap, 1994; Berry, 2002; Hodge, 2006; Hook et al., 2010; Koenig et al., 2015; McCullough, 1999; Pargament, 1997; Pecheur & Edwards, 1984; Propst, 1980; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992; Razali, Hasanah, Aminah, & Subramaniam, 1998; Smith et al., 2007; Tan & Johnson, 2005; Wade, Worthingon, & Vogel, 2007; Worthington & Sandage, 2001; Worthington et al., 2011).

Our research team, led by Drs. Koenig and King, conducted a multi-site randomized controlled trial of religiously-integrated CBT (adapted for Christianity, Judaism, Islam, Buddhism, and Hinduism) versus conventional CBT for the treatment of depression among medically ill individuals (Koenig, Pearce et al., 2015). We found that religiously-integrated CBT was as effective as conventional CBT in reducing symptoms of depression immediately after treatment (12 weeks) and also three months later, and that it was more effective among those who were more religious.

Religiously-Integrated CBT: A Therapeutic Approach for Treating Depression in Religious Clients

CBT is the most empirically studied and validated treatment for depression (Chambless & Ollendick, 2001). The CBT model rests on the premise that symptoms of depression reflect deficits in cognitive and behavioral skills and functioning. As clients learn skills for changing their unhelpful thinking patterns and behaviors, they can experience a lessening of depressive symptoms.

Religiously-integrated CBT (RCBT) is based on the same principles as is conventional CBT. Both are structured and directive, emphasize a collaborative partnership between the therapist and client, set specific session agendas and treatment goals, use Socratic questioning, identify, challenge, and seek to change unhelpful beliefs, modify behavior patterns, and solicit client feedback (Tan, 2007).

RCBT is unique because it intentionally and explicitly uses clients’ religious worldview, beliefs, practices, values, and resources as the foundation for the application of CBT. In other words, therapists help clients to harness their religious resources and worldview to challenge and change dysfunctional beliefs and behaviors in order to reduce depressive symptoms (Pearce et al., 2014).

RCBT promotes positive attitudes and behaviors, such as gratitude, generosity, forgiveness, acceptance, hope, and altruism. The goal is to create an optimistic, purpose-driven, and meaningful outlook that is consistent with the client’s religious worldview and incongruent with depression.

Specific components of RCBT include the following:

• Challenging and changing thoughts using religious teachings
• Contemplative prayer
• Scripture memorization to renew the mind
• Engaging in religious practices (e.g., gratitude, altruism, forgiveness)
• Involvement in a religious community
• Acknowledging and addressing spiritual struggles
• Examples on how to employ RCBT can be found in the upcoming book publication as well as these manuals.

Summary

Integrating religion into psychotherapy is more than inquiring about our clients’ religious affiliation or the importance of their faith. Integrating religion into psychotherapy means actively engaging and utilizing our clients’ faith to achieve psychological gains. Although a majority of clients are answering the question “Does religion belong in psychotherapy?” with a resounding “yes,” many mental health professionals are not taught how to engage with religious issues in therapy. This means a potentially healing resource often goes unnoticed and untapped.

An accumulating body of scientific research shows that our clients’ religious beliefs, practices, and resources can have a positive and powerful impact when integrated into psychotherapy. Religiously-integrated CBT (RCBT) is an effective psychological approach for treating depression among religious clients (Koenig et al., 2015). RCBT uses a client’s own religious beliefs and practices as a foundation to change depression-maintaining beliefs and develop positive behaviors incongruent with depression. For a detailed description of RCBT, see Pearce et al., 2014.

In summary, religion can play an important role in psychotherapy for religious clients. Knowing how to appropriately integrate religion into therapy for individuals who desire this allows us to better serve our clients and our profession.

*This article is a modified excerpt from a recently released book from Dr. Pearce titled: “Cognitive Behavioral Therapy for Christians with Depression: A Practical, Tool-Based Primer.” The book is designed to be a practical guide to help mental health practitioners use religiously-integrated CBT, and its seven specific religiously-integrated CBT tools, with their Christian clients for the treatment of depression. For more information, please visit:  https://www.templetonpress.org/book/cognitive-behavioral-therapy

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Michelle J. Pearce, Ph.D.