The following is a paper I originally wrote March 27, 2017 for COUC 730: Issues in Integration class at Liberty University.
Abstract
Christian accommodative approaches to cognitive-behavioral therapy (CBT) were identified and discussed. Biblical support and empirical support for the use of this therapy was acknowledged and argued. Leading figures in the field were identified and their contributions highlighted. Several studies were selected and discussed for the purpose of illustrating the history of Christian approaches to CBT over the last 40+ years. Christian approaches to CBT have been shown to be as effective as or more effective than its secular counterpart. Despite the promising results from the literature, further research is needed.
Keywords: Christian accommodative CBT, religion, spirituality, biblical, empirical
Evidence-Based Spiritual Intervention Critique: Christian Accommodative Cognitive Therapy
Numerous counseling therapies are available for counselors to utilize in their work with clients; however, the most widely utilized form of therapy has been cognitive-behavioral therapy (CBT), or its various alterations (e.g., mindfulness-based CBT, acceptance and commitment therapy [ACT], dialectical behavior therapy [DBT], among many other therapies derived from CBT) (Anderson, Zuehlke, & Zuehlke, 2000; Jennings, Davis, Hook, & Worthington, 2013). Cognitive-behavioral therapy, founded from the work of Aaron Beck (i.e., cognitive therapy) and Albert Ellis (i.e., rational emotive behavioral therapy), is a secular, common sense, time-limited, goal-focused form of therapy focused on targeting and replacing problematic thoughts that negatively affect emotions and behaviors (Anderson, Zuehlke, & Zuehlke, 2000; Corey, 2001; Jennings, Davis, Hook, & Worthington, 2013; McMinn & Campbell, 2007; Shields & Bredfeldt, 2001). The goals of CBT is, through to challenge and replace problematic or irrational thoughts and beliefs with rational cognitive thoughts, irrational behaviors will be replaced by positive, healthy behaviors (Anderson, Zuehlke, & Zuehlke, 2000; Jennings, Davis, Hook, & Worthington, 2013). This paper will focus on the Christian accommodative approach to CBT. Biblical and empirical support for the use of Christian accommodative CBT will be discussed in the following sections.
Part One: Biblical Support
Identification of Spiritual Intervention
Christian accommodative cognitive therapy is very similar to secular forms of CBT in that clients are made aware of their problematic thought processes in relation to certain triggers or Biblical untruths, how these automatic thoughts influence maladaptive behaviors, and are taught how to recognize and change future dysfunctional thoughts that lead to inappropriate behaviors (Anderson, Zuehlke, & Zuehlke, 2000; Jennings, Davis, Hook, & Worthington, 2013; Worthington, Hook, Davis, & McDaniel, 2011). Anderson, Zuehlke, and Zuehlke (2000) noted clients have very little control over their emotions; however, when clients take charge of their thoughts and beliefs, their emotions and behaviors are then directly affected. Often one’s beliefs need to be challenged because they are rooted in an untruth. The goal of CBT is to challenge and replace problematic or irrational beliefs with rational cognitive thoughts that produce desired behaviors (Anderson, Zuehlke, & Zuehlke, 2000).
Christian accommodative cognitive therapy takes the process of CBT and applies a Christian perspective by way of prayer, scripture, Christian imagery and/or mystical practices (e.g., contemplative or centering prayer), with possible goals of deepening spiritual growth or becoming more Christ-like (Jennings, Davis, Hook, & Worthington, 2013; Knabb, 2012; Mohr, 2011; Worthington, Hook, Davis, & McDaniel, 2011). Biblical teachings concerning the self, the world, and the future are integrated into the basis for treatment, homework assignments, exposure of dysfunctional belief systems, and uncovering basic assumptions that fuel the dysfunctional belief systems (Pecheur & Edwards, 1984). It has been indicated there are parallels between the processes of Christian accommodative CBT and secular CBT. Pecheur (1978) identified similarities between the development of spiritual growth (i.e., sanctification) for the believer and the process of change taking place in cognitive therapy: (a) the believer becomes aware of their thoughts of the flesh (i.e., maladaptive and dysfunctional thought processes are identified); (b) the believer is introduced or re-introduced to the Word of God (i.e., education on healthy and unhealthy thought processes); (c) through the Holy Spirit, the believer is able to cast off thoughts of the flesh and focus on Christ-like thoughts and behaviors (i.e., reframing of negative thoughts and development of healthy thought processes and behaviors); and (d) the believer continues their spiritual growth through prayer, meditation, worship, etc. (i.e., automatic awareness of irrational thoughts and replacement with healthy, rational thoughts).
Vasegh (2011) cautioned therapists of the use of religiously based materials in their work with clients. Clients’ religious and spiritual beliefs must be taken into consideration as dysfunctional thought patterns have been known to develop through religious and spiritual belief systems, and as a result exacerbate psychological symptoms (e.g., excessive guilt) (Dein, 2013; Vasegh, 2011). Vasegh (2011) argued without a thorough understanding of religiously based materials and a clear understanding of the client’s religious and spiritual belief system; treatment will be counterproductive and unsuccessful. Religiously based materials should be used as a natural part of the therapeutic process to bring about healthy changes (Vasegh, 2011). Also of note, the utilization of religiously and spiritually based materials should be mutually agreed upon by both the therapist and the client, particularly the client, to minimize the chance to impose the therapist’s beliefs onto the client (American Association of Christian Counselors, 2014; American Counseling Association, 2014).
Biblical Supporting Evidence
Anderson, Zuehlke, and Zuehlke (2000) point out the practice of CBT is much like that of Christian repentance. Repentance occurs when the Christian is in agreement with the Word of God, acknowledges and turns away from their sin (Romans 14:23), and adopts and exhibits Christ-like behaviors (Philippians 3:17-21). The cognitive-behavioral approach of therapy calls for the transformation of the mind, which makes this form of therapy especially appealing for Christian adaptation, particularly by taking every thought captive (Romans 12:1-2; 2 Corinthians 10:5; Anderson, Zuehlke, & Zuehlke, 2000; Clinton & Ohlschlager, 2002; Jennings, Davis, Hook, & Worthington, 2013).
Anderson, Zuehlke, and Zuehlke (2000) argued, it is not good enough to stop negative thoughts without, consciously and continuously, choosing to replace those thoughts with the truth of God’s Word. The Apostle Paul, through his many letters, counseled his followers on the importance of Christ-like thinking and action (see Romans 8:1-17; Galatians 5:1; Philippians 4:6-9; Colossians 3:15-17). Clinton and Ohlschlager (2002) discussed, clients often get stuck in their stubborn ways of thinking and are focused on external change (e.g., husband, wife, friend, etc. have to change), rather than being focused on internal change (e.g., what an individual needs to do to change their thoughts and behaviors). Jesus cautioned His followers on this principle of dysfunctional thinking (see Matthew 15:10-11).
From a Christian perspective, faulty and dysfunctional thinking (i.e., cognitive distortions) are lies from Satan (Anderson, Zuehlke, & Zuehlke, 2000). The Apostle Paul points out how Satan attempts to use his powers of deception to deceive and mislead the world away from Christ, harden their hearts, and make people believe his thoughts as their own because Satan is the “father of lies” (see 1 Chronicles 21:1; John 8:44; 2 Corinthians 3:14, 4:4; 11:3; Revelation 12:9; Anderson, 2013). Often this happens due to lack of knowledge (Hosea 4:6) and ignorance of Satan’s schemes (2 Corinthians 2:11), or stubborn adherence to human reasoning (Proverbs 3:5-6; Anderson, 2013). Anderson (2013) described the way to win the battle over negative mental cognitions (i.e., desires of the flesh or the lies of Satan) is to fight with the truth of God’s Word (John 8:32; John 17:15, 17-19).
Anderson (2013) provided an example of Plan A (i.e., living by faith) and Plan B (i.e., living by human reasoning) thinking that leads to a battle of the believer’s mind. Living either by Plan A or Plan B is purely a matter of choice. The focus of Plan A is a committed belief in God and that His way is always right. The focus of Plan B is on the self and against God’s Word. Anderson (2013) explained that the more an individual stays focused on their plan (Plan B), instead of God’s plan (Plan A), the more unstable their spiritual growth (see James 1:2-8). Plan B (i.e., human reasoning) thoughts originate from three different areas: (a) the flesh (e.g., temptation); (b) the fallen world (e.g., environmental stimulation); and (c) Satan, false prophets and teachers, mediums, and spiritists (Anderson, 2013). To counteract Plan B thinking conscious efforts are needed to focus on the will of God and the Word of God (see Romans 5:1-11; Ephesians 6:10-20; 2 Corinthians 10:3-5; Anderson, 2013). Through conscious and consistent efforts to focus on godly things, the Holy Spirit enables believers to know God better and to feel His presence, allowing the Christian to feel true joy and freedom (i.e., positive cognitive change) in Christ (Collins, 1993).
Part Two: Empirical Support
CBT was originally developed through the work of Aaron Beck and Albert Ellis as a time-limited, goal-oriented, and common sense secular form of therapy (Anderson, Zuehlke, & Zuehlke, 2000; Jennings, Davis, Hook, & Worthington, 2013; McMinn & Campbell, 2007; Shields & Bredfeldt, 2001). CBT has been the fastest growing and most utilized form of mental health treatment (Anderson, Zuehlke, & Zuehlke, 2000). CBT is easily adaptable and has been shown to be effective for people with various mental health conditions, most notably anxiety and depression (Knabb, 2012). Over the last 40+ years Christian adaptation of CBT has emerged, and has shown to be as effective or more effective than secular forms of CBT, particularly for clients who have identified with having a religious or spiritual background (Hook, Worthington, Davis, Jennings, Gartner, & Hook, 2010; Koenig et al., 2014; McCullough, 1999; Pecheur, 1978; Pecheur & Edwards,1984; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992; Stanley et al., 2011; Worthington, Hook, Davis, & McDaniel, 2011).
The Who, What, When, Where, and How of Christian Accommodative Cognitive Therapy
Leading figures in the field. Several prominent leaders in the field of integration played significant roles in the creation of Christian accommodative approaches to CBT (Jennings, Davis, Hook, & Worthington, 2013). Numerous approaches have been developed and adapted over the years. Methods developed for the purpose of integrating religiosity and spirituality with CBT include: cognitive approaches to lay counseling (Backus, 1985; Crabb, 2013); misbelief therapy (i.e., cognitive restructuring; Backus, 1985); integrative psychotherapy (McMinn & Campbell, 2007); biblical approaches to CBT (i.e., ethical uses of prayer, Scripture, inner healing; Tan, 1987); religious imagery (e.g., visualizations of Christ helping the client through a difficult situation; Propst, 1980).
Historical and current events. Over the course of the last 40+ years, various studies have been conducted for the purpose of determining the efficacy of Christian accommodative approaches to CBT over the traditional form of CBT. Many studies have determined either Christian accommodative approaches to CBT are as effective as or more effective than the traditional form of CBT (Hook, Worthington, Davis, Jennings, Gartner, & Hook, 2010; Jennings, Davis, Hook, & Worthington, 2013; McCullough, 2010). A comprehensive review of studies is not plausible for this paper; however, several studies conducted over the last 40 years will be selected and reviewed to illustrate the efficacy of Christian accommodative approaches to CBT.
Propst (1981) conducted a study with college students to determine the efficacy of religious or nonreligious imagery in the treatment of mild depressive symptoms. The purpose of the study was to determine the legitimacy of replacing depressive imagery with religious or nonreligious content. Two areas of assessment were identified for this study: (a) therapeutic benefit of altering depressive imagery by evaluating two different treatment conditions (i.e., self-monitoring plus therapist and self-monitoring only); and (b) the impact on the use of religious or nonreligious imagery being encouraged between two different treatment conditions. Propst (1980) found the utilization of religious imagery was shown to decrease depressive symptoms on self-report and behavioral measures significantly.
Pecheur and Edwards (1984) conducted a study with Christian college students comparing secular and religious forms of cognitive therapy for the treatment of depression. The purpose of the study was to assess two areas of interest: (a) to determine the ethical and effective administration of Beck’s cognitive therapy for the treatment of depression in a religious population; and (b) to determine the efficacy and benefit to subjects of religious integration on Beck’s cognitive therapy for the treatment of depression. In contrast to the previous study reviewed, Pecheur and Edwards (1984) found that, while both secular and religious CBT groups shown to be considerably more effective than the wait-list control group in decreasing depressive symptoms, no substantial differences were uncovered between secular and religious CBT groups.
Propst, Ostrom, Watkins, Dean, and Mashburn (1992) conducted a study to determine the effectiveness of religious or nonreligious CBT in the treatment of clinical depression with religious patients. Additionally, the study evaluated the benefits of a pastoral counseling treatment that included the important tenets of CBT. There were three purposes of the study to include: (a) evaluation of the effectiveness of religious and nonreligious CBT treatment for depression in religious patients; (b) evaluation of the effectiveness of these therapies when compared to pastoral counseling; and (c) the evaluation of the effectiveness of religiously adapted cognitive therapy to meet the values of the patient by nonreligious therapists. Propst et al. (1992) found patients in the religious and pastoral counseling treatment groups described significantly fewer depressive symptoms than either the nonreligious or wait-list treatment groups.
McCullough (1999) conducted a meta-analysis of five studies to determine the efficacy of religious accommodative approaches for the treatment of depression. Studies included in the meta-analysis had to meet the following requirements: (a) demonstrate a comparison of a religious accommodative approach to counseling to a secular approach to counseling; (b) subjects were randomly assigned to treatment conditions; (c) study participants met specific criteria of psychological symptoms; (d) amount of treatment offered between religious or secular conditions had to be equal. McCullough (1999) found religious accommodative approaches to counseling were no more or less effective than secular approaches to counseling, and the addition of religious content in the counseling session was dependent on client preference.
Stanley et al. (2011) conducted a study with older adults (i.e., 55 years or older) to determine whether these patients preferred the addition of religion or spirituality into their treatment for anxiety and depression. The purpose of the study was to develop new research that acknowledged the importance of religious and spiritual integration with well-established forms of treatment for anxiety and depression for older patients. Stanley et al. (2011) indicated the importance of understanding patient preferences, coping mechanisms, and beliefs, related to integrated approaches mental health treatment, for the purpose of new treatment development for the given population. Stanley et al. (2011) found patients preferred the integration of religion and spirituality in their treatment for anxiety and depression, and indicated better coping, improved problem-solving abilities, and increased faith.
Koenig et al. (2014) conducted a study with religious individuals with chronic medical illnesses to determine the effectiveness of religious vs. secular forms of CBT for the treatment of depression. The premise of the study was threefold: (a) religious involvement (e.g., views and belief system, practices, activities) was related to fewer depressive symptoms, despite demographic, physical health, and social influences; (b) regardless of the affirmative association between poor physical health and increased depressive symptoms, the association is reduced among those who are more religiously involved; and (c) engagement in religious activities was definitively linked to increased meaning and purpose, hopefulness, generosity, and gratitude. Koenig et al. (2014) found no association between religiosity and depressive symptoms, nor did they find an association between chronic medical illness and depression; however, the results indicated an association between increased participation in religious activities promoted improved emotions, which could positively affect depressive symptoms over time.
Assumptions. Christian accommodative approaches to CBT hold many of the same assumptions as its secular counterpart; however, there are some differences that will be discussed in this section. CBT assumes that maladaptive beliefs concerning a particular event lead to maladaptive emotions and problematic behaviors; however, by challenging and replacing those cognitive distortions, rational behaviors will replace irrational and unhealthy behaviors (Anderson, Zuehlke, & Zuehlke, 2000; Corey, 2001; Jennings, Davis, Hook, & Worthington, 2013; McMinn & Campbell, 2007; Shields & Bredfeldt, 2001). Pecheur (1978) found the theoretical assumptions of CBT to be very similar to that of the biblical view of the personal responsibility for one’s behavior.
A Christian approach to CBT assumes client change is possible through the hope that is revealed in Scripture (Anderson, Zuehlke, & Zuehlke, 2000; Jennings, Davis, Hook, & Worthington, 2013). Clients are taught to assess their current thoughts and beliefs and compare those thoughts and beliefs to what the Bible teaches about people, the life and works of Christ, and what is revealed through Scripture as those are the foundation for life, relationships, and hope. The importance of Scripture is heavily relied upon in Christian approaches to CBT as a means to dispute irrational thoughts and beliefs by replacing them with righteous behaviors and character. Jennings, Davis, Hook, and Worthington (2013) argued situations and environments should not dictate one’s emotions and behaviors, but that believers are to focus their thoughts on the truth of Scripture and hope in God through Christ (see Psalm 42:5; 62:5-8; Jeremiah 29:11; Romans 15:4; 2 Timothy 1:6-8; 1 Peter 1:13-16). Ultimately, through the Holy Spirit, the believer can cast off thoughts of the flesh and focus on Christ-like thoughts and behaviors (Pecheur, 1978)
Techniques. The purpose of Christian accommodative approaches to CBT is to assist clients in the appraisal of their maladaptive thoughts and beliefs in contrast to the biblical views of people, life and works of Christ, and the Word of God (Jennings, Davis, Hook, & Worthington, 2013). Therapists incorporate some religious and spiritual tools into their work with clients through the use of prayer, meditation, reading of Scripture, devotional work, Bible study, etc. The reading of Scripture helps reinforce honorable thoughts and behaviors and the truth of God’s Word (see Proverbs 31:10-31; Matthew 7:18; 1 Peter 3:16). Propst (1988) developed a technique of replacing depressive images with religious imagery (e.g., the client visualizes Christ being with them during a stressful situation). Tan (2007) developed the technique of inner healing prayer that has been shown to be especially useful with clients who have unresolved trauma.
Biblical and empirical support for the use of Christian accommodative CBT was discussed in the previous sections. Christian accommodative CBT has emerged over the last 40+ years as an effective form of treatment for depression and anxiety, especially among religious and spiritual clients (Hook, Worthington, Davis, Jennings, Gartner, & Hook, 2010; Koenig et al., 2014; McCullough, 1999; Pecheur, 1978; Pecheur & Edwards,1984; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992; Stanley et al., 2011; Worthington, Hook, Davis, & McDaniel, 2011). Christian accommodative approaches to CBT have been shown to be as effective as or more effective than its secular counterparts; however, additional studies are needed for continued support.
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