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Religion and Spirituality in Psychotherapy: A Practice-Friendly Review of

Research

Article  in  Journal of Clinical Psychology · February 2009

DOI: 10.1002/jclp.20563 · Source: PubMed

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 Religion and Spirituality in Psychotherapy: A Practice-
Friendly Review of Research
m

Brian C. Post and Nathaniel G. Wade

Iowa State University

The role of religion and spirituality in psychotherapy has received

growing attention in the last two decades, with a focus on
understanding the ways that religion and spirituality relate to
therapists, clients, and treatment methods. The authors reviewed
recent empirical research on religion and spirituality in psychotherapy
to inform practitioners about effective ways to incorporate the sacred
into their clinical work. Three main areas are covered: religion/
spirituality and therapists, religion/spirituality and clients, and
religious/spiritual interventions. Research indicates that therapists
are open to religious/spiritual issues, that clients want to discuss
these matters in therapy, and that the use of religious/spiritual
interventions for some clients can be an effective adjunct to traditional
therapy interventions. & 2009 Wiley Periodicals, Inc. J Clin Psychol: In
Session 65:131–146, 2009.

Keywords: religion and spirituality; psychotherapy; religious interven-

tions; clinical research

Introduction
A movement within the mental health professions to understand and address the
sacred has surfaced in recent years. This trend can be attributed to the following
developments: research showing a positive relationship between religion and health;
the majority of the general public in the United States identifying as religious or
spiritual; and the ascendancy of multicultural counseling encouraging sensitivity to
cultural diversity, which includes the religious and spiritual (Hage, Hopson, Siefel,
Payton, & DeFanti, 2006). The practical question for clinicians is no longer whether
to address the sacred in psychotherapy with religious and spiritual clients, but rather,
the questions are when and how to address the sacred. However, these are not easy
questions to answer. In this article, we hope to assist practitioners in understanding

Correspondence concerning this article should be addressed to: Brian Post, Department of Psychology,
Iowa State University, Lagomarcino W112, Ames, IA 50011; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 65(2), 131--146 (2009) & 2009 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20563
132 Journal of Clinical Psychology: In Session, February 2009

the clinical implications of recent empirical studies on religion and spirituality in

psychotherapy and begin to answer these questions.

Our Review of the Clinically Relevant Research

Differentiating between the terms religious and spiritual is difficult because they have
overlapping meanings, and yet are recognized as distinct (Hage et al., 2006).
In addition, researchers have not agreed upon a definition of these constructs
(Richards & Bergin, 2005). The term religious, as it is most commonly understood,
implies an affiliation with an institutionalized religion and affirmation of theological
doctrine or dogma. The term spiritual most often refers to a connection to the
transcendent which for some is disconnected from organized religion (Sperry &
Shafranske, 2005). Accordingly, a person can be religious and spiritual, religious but
not spiritual, spiritual but not religious, or neither religious nor spiritual
(Worthington, Kurusu, McCullough, & Sandage, 1996). For our purposes, we use
the term religious/spiritual when referring to both concepts. When either religious or
spiritual appear alone it is to intentionally communicate that one concept is being
discussed to the exclusion of the other.
We reviewed published, empirical studies that address therapists and religion/
spirituality, clients and religion/spirituality, and religious/spiritual interventions. The
review began with a search on PsychINFO for the root terms spirit or relig in either
the title or the abstract. We crossed this search with the root terms counsel, therap, or
psychotherapy in the title or the abstract. The search was limited to articles published
between 1997 and 2007, in an effort to provide clinicians with a review of the most
current research. For articles on this topic prior to 1997, the reader is referred to
Worthington et al. (1996). Additional articles were obtained by reviewing the
reference lists of articles found on PsychINFO. We did not intend for this review to
be a comprehensive summary of psychotherapy and religion/spirituality, but rather
we aimed for a concise synthesis of empirical research on the topic with practice
implications. Therefore, the following types of articles were selected for inclusion in
this review: meta-analyses, narrative reviews, and empirical articles that were
particularly informative for clinicians.

Therapists and Religion/Spirituality

Many psychotherapists address the sacred in psychotherapy, but what, if anything,
does this say about the religiosity and spirituality of practitioners themselves?
Delaney, Miller, and Bisonó (2007) surveyed the religiosity and spirituality of 258
members of the American Psychological Association (APA) to make comparisons to
both a sample of psychologists surveyed in 1985 (Bergin & Jensen, 1990) and a recent
sample of the United States general public (see Table 1). Psychologists surveyed in
the recent study were no less or more religious than those surveyed two decades ago.
In addition, they remain much less religious than the population they serve. For
example, 35% of psychologists compared to 72% of the public, agreed with the
statement, ‘‘My whole approach to life is based on my religion.’’ Similarly, 48% of
psychologists compared to only 15% of the public indicated that religion was not
very important in their life. Psychologists were also 5 times more likely than the
public to deny belief in God, and of those individuals that reported having ever
believed in God, 25% of psychologists compared to only 4% of the public reported
that they no longer do.
Journal of Clinical Psychology DOI: 10.1002/jclp
 Religion and Psychotherapy 133

Table 1
Summary Table of Research on Therapists and Religion/Spirituality in Therapy

Author (Year) Topic Participants Major findings

Delaney, Miller, Religiosity and Members of the American Psychologists are much less
and Bisonó spirituality among Psychological Association religious than the clients
(2007) psychologists (N 5 258) they serve. However, the
majority of psychologists
believed religion to be
beneficial (82%) rather
than harmful (7%) to
mental health.
Hage, Hopson, Multicultural training Training directors and program Training directors and
Siegel, in religion/ leaders in counselor program leaders across
Payton, and spirituality education, clinical disciplines reported that
DeFanti psychology, counseling students receive minimal
(2006) psychology, marriage and education and training in
family therapy, religious/spiritual diversity
rehabilitation psychology, and interventions.
and psychiatry
Johnson, Hayes, Therapists discuss how Psychotherapists experienced in A pluralistic approach to
and Wade they approach working with spiritual clients’ spirituality was
(2007) working with problems in psychotherapy used by most therapists.
religious and (N 5 12) They conceptualized
spiritual clients spiritual problems as
intertwined with other
psychological and
relational problems.
Therapists noted that
spiritual problems often
emerged gradually over
the course of therapy.
O’Connor and Mental health Mental health practitioners The further a religious belief
Vandenberg professionals (N 5 110) was from mainstream
(2005) assessment of the religious beliefs (i.e.,
pathognomonic Christianity), the higher
significance of rating of pathology it was
religious beliefs assigned.

By contrast, the majority of psychologists indicated that spirituality was either

‘‘very important’’ (52%) or ‘‘fairly important’’ (28%) to them. No comparison can
be made to the 1985 sample of psychologists because no measures of spirituality were
included in that survey. One possible explanation for the absence of such measures is
that psychologists as a group tend to embrace spirituality more commonly today
than they did in the mid-1980s. Whatever the reason, psychologists today are more
likely to describe themselves as ‘‘spiritual but not religious’’ than the population they
serve (Delaney et al., 2007). Still, it seems that most psychologists view the religiosity
of their clients positively. Of the psychologists surveyed, the majority believed
religion to be beneficial (82%) rather than harmful (7%) to mental health. That the
majority of psychologists believe in the positive relationship between religiosity and
mental health, however, does not mean that they necessarily have the knowledge and
skill to work with religious clients effectively.
A recent analogue study illustrated that clinical judgment can be altered when
practitioners are unfamiliar with the religious beliefs of a client (O’Connor &
Vandenberg, 2005). After reading one of three vignettes depicting clients possessing
Journal of Clinical Psychology DOI: 10.1002/jclp
134 Journal of Clinical Psychology: In Session, February 2009

the beliefs associated with Catholicism, Mormonism, and Nation of Islam, mental
health professionals (N 5 110) rated the clients on a number of therapeutic
dimensions including pathology of beliefs. Responding mental health professionals
considered the beliefs associated with Catholicism to be significantly less
pathological than beliefs associated with the less mainstream religions (Mormonism
and Nation of Islam). The beliefs of Mormonism were considered to be significantly
less pathological than the beliefs of the Nation of Islam, the least mainstream of
the three religions in the United States. In other words, the further the religious
belief was from mainstream religious beliefs (i.e., Christianity), the higher clinicians
rated it in terms of psychotic pathology. In addition, both Catholic and Mormon
beliefs were rated as significantly less pathological when they were identified with
their respective traditions. However, the beliefs for Nation of Islam were rated as
highly pathological regardless of whether they were described as part of the religion
or not.
Clinicians’ lack of familiarity with the less mainstream religions (e.g., Mormonism
and Nation of Islam) may have been responsible for the discrepancy in ratings of
psychotic pathology (O’Connor & Vandenberg, 2005). This may be particularly
troubling because such unfamiliarity may be more the rule than the exception.
Graduate students in clinical psychology, counselor education, counseling psycho-
logy, marriage and family therapy, and psychiatry receive minimal education and
training in working with clients from diverse religious/spiritual backgrounds (Hage
et al., 2006). For example, in a survey of training directors and program leaders, only
13% reported that their APA-accredited clinical psychology program offers a
specific course in religion/spirituality and psychology; 17% reported that the topic is
covered systematically; and 16% reported that their program does not address the
topic at all (Brawer, Handal, Fabricatore, Roberts, & Wajda-Johnston, 2002). It is
no wonder that clinicians may struggle to be open to and supportive of their clients’
religiosity/spirituality when the client espouses a less familiar religious tradition.

Clinical Implications of Research on Therapists and Religion/Spirituality

One way for clinicians to enhance their ability to work effectively with religious/
spiritual clients is to look to those who already do so. A recent qualitative study did
so by asking 12 psychotherapists—who were nominated by their peers as therapists
who were experienced in treating religious/spiritual problems—to describe how they
approach, assess, and treat religious/spiritual problems (Johnson, Hayes, & Wade,
2007). These clinicians used a pluralistic approach to clients’ religious/spiritual
beliefs most often; that is, they appreciated diverse religious/spiritual paths and were
careful not to impose their own values on their clients. These clinicians
conceptualized religious/spiritual problems through several frameworks. For
example, many used a developmental lens (e.g., Fowler’s stages of faith; Fowler,
1981) or understood religious and spiritual issues as intertwined with other
psychological and relational problems (Johnson et al., 2007). Most of these
therapists noted that religious/spiritual problems often emerged gradually over the
course of therapy. Once emerged, the clinicians used a number of techniques, many
of which were explicitly spiritual interventions tailored to a client’s personal
spirituality (e.g., meditation, quoting scripture, and prayer). A common religious/
spiritual intervention method, and perhaps, the most important in terms of
facilitating discussion about such problems, was an explicit statement or discussion
communicating openness to exploring religion/spirituality with the client.
Journal of Clinical Psychology DOI: 10.1002/jclp
 Religion and Psychotherapy 135

In addition to learning from therapists experienced in addressing the sacred in

psychotherapy, clinicians can become more self-aware to enhance their work with
religious/spiritual clients (Bartoli, 2007). Awareness of one’s own beliefs and biases
regarding religion/spirituality will help therapists avoid imposing their own values on
their clients. One method for exploring one’s own spiritual ideas and values is to
write a spiritual autobiography (Wiggins, 2008). In a spiritual autobiography,
therapists can explore the education, experiences, and events that have led them to
their present spirituality. Wiggins (2008) suggests using not only narrative prose to
tell the story of one’s spiritually and religious history, but also spiritual family
genograms that chronicle the religious/spiritual beliefs, commitments, and experi-
ences of one’s extended family.

Summary of Research on Therapists and Religion/Spirituality

Based on the research we have reviewed, there are three main reasons that therapists
may want to evaluate their own stance toward religion/spirituality. First, they are
more inclined than their clients are to be ‘‘spiritual but not religious’’ (Delaney et al.,
2007), and many clients will have religious or spiritual commitments. Second, despite
the need for specific training, therapists are unlikely to receive encouragement to
explore their own religious/spiritual beliefs and biases in graduate school (Hage
et al., 2006). Third, they may make poorer clinical judgments regarding religious
beliefs for which they are unfamiliar (O’Connor & Vandenberg, 2005).

Clients and Religion/Spirituality

Considerable research has also been conducted on clients and religion/spirituality.
(For a summary of the articles reviewed in this section, see Table 2.) Over a decade
ago, Worthington et al. (1996), in a review of empirical research on religion and
psychotherapy, challenged researchers to move away from conducting analogue
studies, which had been the most common type of research at that time, and focus
their research on actual clients. One of the first studies to respond to this challenge
examined beliefs and preferences of 74 clients at nine counseling agencies regarding
discussion of religious/spiritual issues (Rose, Westefeld, & Ansley, 2001). Most of
these clients believed that it was appropriate to discuss religious/spiritual concerns in
therapy (63%) and indicated that they wanted to do so (55%). Comparatively, a
minority of clients (18%) reported that they preferred not to discuss such topics in
therapy. They listed several reasons, such as preferring to discuss them with clergy
(4%) or believing they were not relevant to their presenting problem (11%).
It is also noteworthy that, unlike many previous studies on religion and
psychotherapy that had focused primarily on Christians, participants in this study
were religiously/spiritually diverse; 60% reported some religious affiliation and 40%
reported no religious affiliation (compared to the 90% of the general public that
reports a religious affiliation). Consequently, an important clinical implication of
this study is that, even in a sample of clients who were not all religiously affiliated,
most believed that it was appropriate and desirable to discuss religious/spiritual
issues in therapy.
Religion and spirituality are of interest to therapists not only because the majority
of clients prefer to discuss such topics, but also they may be a source of distress for
many clients (Johnson & Hayes, 2003). In a survey of 2,754 clients at the counseling
centers of public universities and private colleges across the United States, 20%
reported a clinically significant level of distress related to religious/spiritual
Journal of Clinical Psychology DOI: 10.1002/jclp
136 Journal of Clinical Psychology: In Session, February 2009

Table 2
Summary Table of Research on Clients and Religion/Spirituality in Therapy

Author (Year) Topic Participants Major findings

Belaire and Conservative Adults (ages 18–79) who were Compared to the group of
Young (2002) Christians’ members of churches or moderately conservative
expectations of religious student Christians, the group of
non-Christian organizations in the mid- highly conservative
counselors South region of the United Christians had significantly
States (N 5 100) higher expectations that a
secular counselor would
utilize explicitly religious
interventions.
Johnson and Prevalence and 2,754 university and college 20% of the clinical sample
Hayes (2003) predictors of students receiving help at reported a clinically
religious and their university counseling relevant level of distress
spiritual concerns center related to religious or
among clients spiritual concerns.
Knox, Catlin, Clients’ experiences Adult clients in individual Religious/spiritual discussions
Casper, and discussing religion outpatient psychotherapy were found to be most
Schlosser and spirituality in with non-religiously helpful when they were
(2005) therapy affiliated therapists client-initiated. Helpful
(N 5 12) discussions arose gradually
within the first year of
therapy. Helpful discussions
were facilitated when clients’
perceived therapists as open,
accepting, and safe.
Martinez, Client opinions and Mormon students receiving Clients rated the following
Smith, and experiences with help at the counseling religious interventions as
Barlow religious center of a large university both appropriate and helpful:
(2007) interventions sponsored by the Church referencing scriptural
of Jesus Christ of Latter- passages, teaching spiritual
Day Saints (N 5 152) concepts, encouraging
forgiveness, involving
religious community
resources, and conducting
assessments of client
spirituality.
Mayers, Leavey, Process of help- Clients with religious or Prior to therapy, clients
Vallianatou, seeking and therapy spiritual in London reported concerns that
and Barker among religious and (N 5 10) secular therapists would
(2007) spiritual clients ignore or insensitively
approach religious/spiritual
beliefs. However, the
majority of clients reported
that their experience of
receiving help from a secular
therapist was positive.
Rose, Westefeld, Clients’ beliefs and Clients at nine counseling The majority of clients believed
and Ansley preferences for sites (N 5 74). 60% that it is appropriate to
(2001) discussion of reported some religious discuss religious concerns in
religious and affiliation and 40% therapy (63%) and indicated
spiritual concerns reported no religious that religious or spiritual
affiliation concerns were something
that they would like to
discuss in therapy (55%).

Journal of Clinical Psychology DOI: 10.1002/jclp

 Religion and Psychotherapy 137

Table 2 (Continued)
Author
(Year) Topic Participants Major findings

Weld and Christian clients’ Adult first-visit clients Most clients felt that it was
Eriksen preferences regarding (N 5 165) and therapists usually the therapist’s
(2007) prayer as a (N 5 32) at three faith-based responsibility to bring up the
counseling counseling agencies subject of prayer. Religious
intervention conservatives, individuals who
had previously received help
from a Christian counselor,
and clients who were more
prayerful in their personal life
had the highest expectations
for including prayer in
counseling.

problems. Some examples of presenting concerns of a religious/spiritual nature

included confusion about values and beliefs and thoughts of being punished for one’s
sins. These results suggest that at least some clients may come to therapy with
religious/spiritual concerns and that therapists should routinely assess potential
religious/spiritual problems and the history and health of a client’s religious/spiritual
beliefs (Johnson et al., 2007).
In this respect, it is important to understand what religious/spiritual clients expect
from both secular and religious counselors prior to treatment. One study compared
the expectations of 100 Christians with moderate and high levels of conservatism
(Belaire & Young, 2002). Both moderately and highly conservative Christians
reported an expectation that a secular counselor would respect their religious beliefs
and hold an open attitude toward religion. However, compared to moderately
conservative Christians, highly conservative Christians had significantly higher
expectations that the secular counselor would use in-session religious interventions
such as audible prayer and scripture references.
In addition to level of conservatism, prior experience with counseling also
influenced participants’ expectations of counseling with a secular therapist.
Irrespective of level of conservatism, Christians with previous experience with
secular counseling reported more favorable expectations for secular counseling than
did participants with no prior experience. Even so, the majority of participants with
and without previous experience with secular counseling reported a preference for a
Christian counselor.
Similar results were found in another study that examined Christians’ expectations
of Christian counselors (Weld & Eriksen, 2007). This study, unlike the preceding one
we reviewed, surveyed actual clients as they arrived for their first session at one of
three faith-based counseling agencies. It specifically focused on Christian clients’
preferences regarding in-session prayer as a counseling method. Participants were
165 adult clients (94.5% of which reported a religious affiliation). Eighty-two percent
of the clients reported a desire for the therapist to audibly pray with them in-session.
The majority felt that it was usually the therapist’s responsibility to bring up the
subject of prayer. This finding could be because the vast majority of clients in this
study were Christians seeking help from therapists who advertised themselves as
explicitly Christian counselors. Participants in this study who had the highest
expectations for the inclusion of audible prayer in therapy were religious
Journal of Clinical Psychology DOI: 10.1002/jclp
138 Journal of Clinical Psychology: In Session, February 2009

conservatives, individuals who had previously received help from a Christian

counselor, and clients who were more prayerful in their personal life. Conversely,
males, younger clients, Catholics, and Christians who were more liberal tended to
have lower expectations that their Christian counselor would include prayer in the
therapy session.
It is helpful for clinicians to be aware of this preference among Christians seeking
faith-based counseling. However, it is also helpful information for those therapists
who might see conservative Christian clients in their secular practices as well.
Assessing these clients’ preferences helps to distinguish those who are interested in
religious/spiritual interventions from those who are not. In a nonreligious practice
setting the assessment might be even more important than in a religious setting.
Some conservative religious individuals may come to a secular practice deliberately
to avoid religious interventions, issues, or questions perhaps as a result of
questioning their faith commitments. Others might come to a secular therapist as
a result of more mundane reasons, such as insurance availability, convenience, or a
strong referral from someone they trust. In these cases, the client may benefit from
a religiously/spiritually integrated treatment approach.
Pretreatment expectations are important, but so too is the actual experience of
psychotherapy (both secular and Christian) as reported by religious clients. One
qualitative study explored the process of help-seeking and therapy by interviewing
10 clients in a secular setting (Mayers, Leavey, Vallianatou, & Baker, 2007). Eight
participants identified themselves as religious. Two indicated that they were spiritual,
but not religious. Participants reported that prior to beginning therapy they had been
concerned that a secular therapist might ignore or insensitively approach their
religious/spiritual beliefs. However, most of the 10 clients reported that receiving
help from a secular therapist was a positive experience. Some went so far as to say
that their faith was strengthened by the experience. Participants expressed mixed
opinions about the importance of being matched with a therapist with similar
religious/spiritual beliefs. Some felt that a mismatch allowed them to gain new
insights, whereas others refrained from discussing religious/spiritual topics until they
were certain that their therapist shared similar beliefs. Overall, clients reported that
the therapeutic alliance was strongest when they felt that the therapist accepted and
respected their beliefs. This finding parallels the desire clients have for therapists to
respect their religious/spiritual beliefs reported in studies discussed later in this
review (Knox, Catlin, Casper, & Schlosser, 2005; Wade, Worthington, & Vogel,
2007).
To examine religious clients’ experiences with explicitly religious psychotherapy,
Martinez, Smith, and Barlow (2007) surveyed 152 Mormon students who were
clients at the counseling center of a large university sponsored by the Church of Jesus
Christ of Latter-Day Saints (LDS). Clients expressed their opinions regarding the
appropriateness and helpfulness of various religious interventions. The majority of
participants considered out-of-session religious interventions more appropriate than
in-session religious interventions, but in-session interventions were rated as more
helpful. Clients reported that the following therapist religious interventions were
both appropriate and helpful in session: references to scripture, teaching spiritual
concepts, encouraging forgiveness, involving religious community resources,
conducting assessments of client spirituality, and self-disclosure about religious/
spiritual issues. For instance, a therapist might refer to scripture by either quoting a
familiar verse or reminding the client of a familiar parable that relates to the problem
being discussed. In addition, the therapist might explain a troublesome point of
Journal of Clinical Psychology DOI: 10.1002/jclp
 Religion and Psychotherapy 139

scripture that the client is having difficulty understanding or is misapplying in a way

that exacerbates the clinical problem. As another example, the therapist might teach
spiritual concepts that the client has referred to or appears open to. A client might be
interested in meditation or mindfulness as a stress reduction method, but the client
might have little idea how to meditate consistent with his or her religion. Applying
basic psychological practices (and concepts) in a way that is consistent with a
client’s religious or spiritual perspective is likely to increase the effectiveness of
the intervention and further contribute to the client’s trust and comfort in the
therapy process.
Conversely, blessings by the therapist (laying-on of hands), therapist–client
prayer, and encouragement to memorize scripture were considered inappropriate by
these religious clients. Some clients explained that these interventions were
inappropriate because a counselor should not act as an ecclesiastical leader. Many
Mormons believe that religious functions should typically be provided by their
religious leaders, whereas many Christians endorse the ‘‘priesthood of all believers,’’
which encourages the laity to act as ministers to each other. Therefore, Christians
seeking help from a Christian counselor might more easily accept in-session prayer
and other types of explicitly religious interventions than would a Mormon client,
whose therapist is not likely to be an ordained minister in the Mormon Church. This
again underscores the necessity of a therapist knowing the client’s beliefs and values
rather than assuming that a religious/spiritual client is open to any religious/spiritual
intervention.

Clinical Implications of Research on Clients and Religion/Spirituality

This and related studies highlight important therapist behaviors. First, therapists
should carefully assess the opinions and needs of their clients regarding
religious interventions and in most cases should seek informed consent. Many
religious interventions, such as in-session prayer, will be favorably received by
some clients and considered as inappropriate by other clients. Second, differences
in theology or spiritual beliefs might have a considerable impact on what clients
hope for, expect, and need in a counseling situation. Although it is helpful for
therapists to be versed in some of the basic tenets of their clients’ religions, it is not
necessary for therapists to be experts in comparative religion. Instead, approaching
religious/spiritual clients with an openness and willingness to engage the religious/
spiritual conversation will help clients to feel comfortable expressing their needs.
Then, if therapists feel comfortable meeting those particular needs (e.g., for in-
session prayer) they can. If they do not, they are in a better position to explain why
they cannot and facilitate a referral to someone (e.g., clergy or religiously focused
therapist) who can.
Research has primarily sampled religious, rather than spiritual, clients. This
pattern reflects an existing bias in the literature to focus on this population, but it
also reflects the much higher proportion of religious individuals in the public. One
qualitative study sampled a group with more spiritual diversity (Knox et al., 2005).
Participants were six individuals who considered themselves either religious or
spiritual, but did not identify with a particular religious or spiritual group, three
Catholics, and three individuals with experiences in various religious/spiritual groups
such as Buddhism, Hinduism, Judaism, paganism, and Unitarian Universalism. All
clients were in individual outpatient psychotherapy with non-religiously affiliated
therapists at the time of their interview.
Journal of Clinical Psychology DOI: 10.1002/jclp
140 Journal of Clinical Psychology: In Session, February 2009

Clients in this study did not typically identify religious/spiritual topics as their core
problem, but rather such topics typically arose naturally and were related to the
clients’ presenting concerns. Clients were asked to reflect on specifically helpful and
unhelpful discussions of religion/spirituality in therapy. Helpful discussions had
often been initiated by clients and arose gradually within the first year of therapy,
whereas unhelpful discussions were raised equally by clients and therapists and
typically occurred early (e.g., first session). Helpful discussions were facilitated when
clients’ perceived therapists as open, accepting, and safe. Discussions became
unhelpful when the client felt judged or perceived that the therapist was attempting
to impose their beliefs. In the most fundamental way, spiritual clients desire the same
thing from their psychotherapists as do religious clients: respect. If clinicians are to
meet this desire they can (a) communicate that they are open to and supportive of
discussing religious/spiritual concerns, (b) routinely assess for religiosity and
spirituality, and (c) always gain consent before using religious/spiritual interventions.

Summary of Research on Clients and Religion/Spirituality

Research indicates that many clients are open to including the religious/spiritual in
their therapy and many want their therapists to do so. Religious/spiritual concerns
may be a significant source of distress for some clients as well. In addition, many
clients expect their therapists to be open to their religious views and to respect their
values and beliefs. One of the most direct and comprehensive ways that therapists
can address these issues early in counseling is to include a religious/spiritual
assessment. Such assessments can be formal (using standardized interview protocols
and normed scales) or informal (using open-ended questions). Assessment of this
sort might occur in the very beginning of therapy, as a part of the structured clinical
intake interview, or it might emerge as a result of something a client says. For
example, when a client shares within the first few sessions that she feels like her
religious congregation provides her with much support, a therapist could easily
follow up with questions about that support, that congregation, her religious beliefs,
and how that has helped her in the past. This informal, spur-of-the-moment religious
assessment can accomplish at least two things. First, it provides information about
the client. Perhaps her religious congregation truly is a great source of support,
maybe it is not. Delving further provides the therapist with useful information about
strengths and liabilities the client brings to her work. Second, this assessment also
communicates to the client that the therapist is open to discussing religious/spiritual
material, is respectful of the client’s religious values and beliefs, and will work with
these concerns to the degree that they relate to the client’s therapeutic goals.

Religious/Spiritual Interventions
It is unlikely that many clinicians would quibble with the need for a posture of
respect and sensitivity highlighted above. Instead, the difficulties lie in the how and
when to offer religious/spiritual interventions. What qualifies as a religious/spiritual
intervention? Are they effective? Are they most effective when delivered by a
religious clinician? We will address these questions in this section (see Table 3 for a
summary of the articles reviewed).
There are at least three common views on defining religious/spiritual interventions
(Worthington, 1986). One view defines religious/spiritual interventions as any secular
techniques used to strengthen the faith of a religious/spiritual client. A second view
Journal of Clinical Psychology DOI: 10.1002/jclp
 Religion and Psychotherapy 141

Table 3
Summary Table of Research on Religiously/Spiritually Tailored Interventions

Author (Year) Topic Participants Major findings

Avants, Beitel, and Spiritual self-schema Cocaine- and opioid- Clients responded ‘‘not me’’ to
Margolin (2005) (3-S) therapy for dependent clients addict qualities significantly
the treatment of enrolled in a faster at posttreatment than
addiction and community-based they did at pretreatment, and
HIV risk behavior methadone faster ‘‘me’’ to spiritual
maintenance program qualities. A shift in self-
(N 5 29) schema from ‘‘addict self’’ to
‘‘spiritual self’’ was correlated
with a decrease in drug use
and other HIV risk behaviors.
Coelho, Canter, and Evaluation of Results for patients with three or
Ernst (2007) research on more previous episodes of
mindfulness-based depression were promising in
cognitive therapy that the number of
for depression individuals that relapsed
within one year was
statistically less for the group
that received TAU plus
MBCT (37%) as compared to
the group that received TAU
(66%).
Murray-Swank and Spiritually integrated Two female survivors of This intervention shows promise
Pargament (2005) manualized childhood sexual in fostering spiritual recovery
intervention for abuse from childhood sexual abuse.
sexual abuse: Both clients increased in
Solace for the positive religious coping,
Soul spiritual well-being, and
positive images of God.
Richards, Berrett, Effectiveness of a Women suffering from Compared to clients treated in
Hardman, and spiritual group anorexia, bulimia, or the cognitive and emotional
Eggett (2006) intervention for eating disorder NOS support groups, clients in the
eating disorder (N 5 122) spirituality group scored
inpatients significantly lower on
psychological disturbance
and eating disorder
symptoms and higher on
spiritual well-being at the
conclusion of treatment.
Smith, Bartz and Meta-analysis of 31 1,845 clients who were Overall, spiritual approaches to
Richards (2007) outcome studies predominantly psychotherapy are effective.
of spiritual Christian or Muslim Spiritual interventions in
therapies which the therapist taught the
conducted from client spiritual concepts and
1984 to 2005 related them to their situation
were significantly more
effective than those spiritual
interventions that did not.
Wade, Effectiveness of Clients (N 5 220) and Congruence between therapists’
Worthington, and religiously tailored their therapists interventions and their
Vogel (2007) interventions in (N 5 51) in 6 Christian clients’ religious commitment
Christian therapy agencies and 1 secular was related to closer
agency across the therapeutic relationships and
United States more beneficial outcomes.

Note. TAU 5 treatment as usual; MBCT 5 mindfulness-based cognitive therapy.

Journal of Clinical Psychology DOI: 10.1002/jclp

142 Journal of Clinical Psychology: In Session, February 2009

defines religious/spiritual interventions as secular techniques modified to include

explicitly religious content (e.g., Christian cognitive therapy). A third view defines
religious/spiritual interventions as an action or behavior derived from religious
practice (e.g., blessings, reference to sacred texts, audible prayer). Here we focus on
religious/spiritual interventions that fall into the second and third categories because
these have received the bulk of the research attention.
In recent years, there has been a proliferation of religiously/spiritually integrated
interventions used by clinicians to treat a range of psychological problems. A recent
narrative review evaluated the preliminary research on mindfulness-based cognitive
therapy for depression and reported promising results for prevention of relapse of
depression for patients with three or more previous episodes of depression (Coelho,
Canter, & Ernst, 2007). Another study on spiritual self-schema (3-S) therapy
reported data that implies that this manualized treatment may help some drug-
addicted individuals shift from the self-schema ‘‘addict self’’ to ‘‘spiritual self’’
(Avants, Beitel, & Margolin, 2005). Such a shift was correlated with a decrease in
drug use and other HIV risk behaviors. Other examples of recent religious/spiritual
interventions include a manualized intervention for sexual abuse victims (Murray-
Swank & Pargament, 2005) and a spiritual group intervention for inpatients with
eating disorders (Richards, Berrett, Hardman, & Eggett, 2006). In addition, many
clinicians continue to implement explicitly religious interventions (e.g., prayer) and
religiously/spiritually integrated interventions (e.g., Christian cognitive therapy).
The natural question is whether these interventions are effective. In many ways,
outcome studies on the effectiveness of such interventions are still in their infancy
(Richards et al., 2006). However, many strides have been made in the last decade.
For example, in 1999, a meta-analytic review on the topic of religiously
accommodative outcome studies included only five studies (McCullough, 1999).
A recent meta-analytic review of outcomes of religious/spiritual interventions
analyzed 31 studies (Smith, Bartz, & Richards, 2007). Clearly, the literature has
expanded, but there is still much room for growth.
Smith and colleagues (2007) combined the data from 1,845 clients with various
religious affiliations. Overall, the studies examined the effects of a variety of religious/
spiritual interventions. No differences were found between individual therapy studies
versus group therapy studies. Nor were differences found between studies of manualized
treatments versus nonmanualized treatments. However, type of religious/spiritual
intervention led to differences for two out of four types of such interventions. Studies
involving interventions in which the therapist explicitly taught clients spiritual concepts
and related the concepts to the clients’ situations were more effective than those that did
not. Conversely, studies involving interventions giving instruction in religious imagery or
meditation were less effective than those studies that did not provide such instruction.
Finally, studies involving client prayer and studies involving reading sacred texts were as
effective as studies that did not include either of these interventions.
Overall, across the 31 studies religious/spiritual approaches to psychotherapy were
effective. In addition, in the 16 studies in which a religious/spiritual intervention was
compared to a secular intervention, the religious/spiritual interventions were more
effective. Based on this observation, the authors argue that further investigation of
the effectiveness of religious/spiritual interventions is certainly warranted. Similarly,
these results should give clinicians reason to consider using such interventions in
therapy with religious/spiritual clients (Smith, Bartz, & Richards, 2007).
Psychotherapists who are not religious or who practice a spirituality that differs
greatly from that of the majority of their clients may feel uneasy with the
Journal of Clinical Psychology DOI: 10.1002/jclp
 Religion and Psychotherapy 143

recommendation to use religious/spiritual interventions in treatment. One concern is

whether clinicians with religious/spiritual beliefs that match the client’s beliefs more
effectively deliver such interventions. One study explored this concern by examining
the relationships between therapist–client religious commitment similarity and the
use of religious interventions with treatment outcome (Wade et al., 2007). Clients
(N 5 220) and their therapists (N 5 51) from secular and Christian counseling
agencies throughout the United States participated. In this study, congruence
between the use of religious interventions and clients’ religious commitment (using
religious interventions with highly religious clients and not with nonreligious
clients) was related to closer therapeutic relationships and more beneficial outcomes.
However, client–therapist match on religious commitment did not predict
closeness or client-rated change. The authors concluded that perhaps what matters
most is not matching between client and therapist on religious commitment, but the
client’s perception that the therapist has an open and respectful posture
toward religion/spirituality and is willing to use interventions that are congruent
with the client’s (and not necessarily the therapist’s) religious commitments. These
findings should give clinicians confidence that they can work effectively with
religious/spiritual clients regardless of whether they personally hold religious/
spiritual beliefs.

Clinical Implications of Research on Religious/Spiritual Interventions

Religious/spiritual interventions can be effective. Nonreligious therapists can
even use some of these interventions effectively with their religious/spiritual
clients. However, how does one do this in an authentic and client-sensitive
way? At the foundation, clinicians can start with an openness toward their
clients’ religious/spiritual practices and worldviews. Therapists can show this
openness by enquiring into the specifics of a client’s religious/spiritual beliefs and
into the ways the client sees religion/spirituality related to the presenting problems.
Open-ended questions can be used, such as ‘‘I’m not overly familiar with that form
of Buddhism (or Christianity, or Judaism), could you tell me more about it and your
experience of it?’’ or ‘‘How do you see your faith relating to your most pressing
concerns?’’
For those with little exposure to a particular client’s religion, more general
techniques, ideas, or concepts might be utilized. For example, a therapist working
with a devout Jew might talk generally about hope for the future and finding courage
to persevere and then enquire how these ideas are expressed in the client’s Judaism.
In addition, clinicians can enquire into what religious/spiritual interventions the
client might want to be included in their therapy. Many clients will be able to identify
those religious/spiritual aspects that they feel strongly about and which they would
like to include in their treatment.
Despite the research that can give general ideas from averages and summaries of
client data, ultimately each client may respond to religious/spiritual interventions
differently. For example, although many religious clients may be interested in
religious/spiritual interventions, some religious individuals might not, believing that
religion is better dealt with by clergy or other religion-ordained leaders. Conversely,
with nonreligious clients, religious interventions are typically not appropriate.
However, on an individual basis, some clients who do not have religious/spiritual
commitments might want or need to talk through experiences with religion or
present religious struggles. Therefore, in such situations, clinicians might
Journal of Clinical Psychology DOI: 10.1002/jclp
144 Journal of Clinical Psychology: In Session, February 2009

appropriately use more general religious/spiritual interventions, such as taking a

religious history or referring to religious/spiritual concepts.

Summary of Research on Religious/Spiritual Interventions

Different forms of religious/spiritual interventions have been used by therapists and
many of these interventions appear to be effective. The majority of religious/spiritual
clients welcome most of the interventions examined by the existing research, and
many, although not all, therapists see these as appropriate as well. The most
researched interventions appear to be typical psychotherapy techniques that are
integrated with a religious perspective (e.g., Christian CBT), mindfulness, prayer,
and teaching religious/spiritual concepts. These interventions appear to help
religiously oriented clients and can be effectively employed by therapists who
themselves are not necessarily religious.

Summary
By way of conclusion and summary, we highlight here the predominant research-
driven themes that are present in the literature that we reviewed and that can be
readily transported to daily practice of psychotherapy.

1. Psychotherapists as a whole tend to identify less with religion and more with
spirituality than the clients they serve. Therefore, it is important that they are
deliberate about identifying their own attitudes and biases concerning religion to
avoid imposing their values on clients.
2. Therapists usually receive little or no education and training in graduate school
regarding religious/spiritual diversity. This may explain why many therapists lack
confidence in their ability to work effectively with religious/spiritual clients. We
thus advise therapists to seek out resources to become informed on this subject.
3. Many religious/spiritual clients want to talk about religious/spiritual matters in
therapy, although this is not unanimous. Psychotherapists can routinely assess
clients’ treatment preferences in this regard.
4. Some clients desire that their therapist use religious/spiritual interventions in
therapy sessions. For many religious/spiritual clients this can be done effectively
by both religious and secular therapists.
5. Religious/spiritual issues are sometimes interrelated with the presenting problems
for psychotherapy. Therefore, therapists should routinely assess for religious/
spiritual history and concerns.
6. Religious/spiritual clients usually find religious/spiritual discussions in therapy
to be most helpful when they are client-initiated and brought up gradually
as opposed to early on (e.g., in the first session). This provides time for
the therapeutic relationship to develop and for the client to develop trust in the
therapist’s acceptance of their religious/spiritual worldview.
7. Empirical evidence suggests that religious/spiritual interventions are often
effective. For this reason, clinicians would do well to consider using them when
appropriate.
8. The effectiveness of religious/spiritual interventions depends more on congruence
with clients’ religious commitment than congruence between therapist–client
religious commitment. Consequently, such interventions can be delivered
effectively by therapists of all religious/spiritual beliefs.

Journal of Clinical Psychology DOI: 10.1002/jclp

 Religion and Psychotherapy 145

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