Evidenced-Based Religious Accommodative Psychotherapy: Practice and Belief

Sutton & Arnzen, 2015 Page 1

Evidenced-Based Religious Accommodative Psychotherapy:

Practice and Belief

Geoffrey W. Sutton & Christine A. Arnzen

Evangel University

Sutton, G. W., Arnzen, C. A. (2015, April). Evidenced-Based religious accommodative

psychotherapy: Practice and belief. Paper presented at the annual meeting of the

Christian Association for Psychological Studies, International Conference, Denver,

Colorado.


Abstract

As research continues to accumulate in support of some psychotherapeutic interventions and not

others, it is incumbent on clinicians to understand and utilize effective practices. In 2013,

Worthington, Johnson, Hook, and Aten edited a 16 chapter volume containing guidance

concerning a variety of interventions linked to Christian counseling and psychotherapy.

Supportive evidence for the interventions varied in kind and scope. In the final reflections

chapter, Johnson, Worthington, Hook, and Aten (2013) referred to the notion of Christian

counseling and psychotherapy as confusing. They cited one study by Wade, Worthington, and

Vogel (2007), which documented what 51 self-identified Christian counselors included in their

practice.

Christianity is the largest religion in the world with more than 2 billion adherents. And

Christianity is the dominant religion in the United States. There is evidence supporting the

importance of considering the religious-spiritual beliefs and values of clients and there is

evidence that some religious accommodative interventions are effective (Worthington, et al.,

2013). However, little is known about the common practices of Christian clinicians. Moreover,

Johnson and others (2013) observed that little is known about the practices of some clinicians

linked to Pentecostal-Charismatic Spirituality (PCS). The purpose of our study was to contribute

additional information on the practices and beliefs of self-identified Christian clinicians.

In this presentation, we report the results of a survey of Christian clinicians. In addition to

recruiting from a wide swath of clinicians, we specifically pursued participation from those

likely to identify with PCS. In addition to probing for interventions utilized during therapy, we

asked about recommended activities between sessions. In an effort to link belief with practice,

we included an empirically-supported scale tapping PCS (Sutton, Jordan, & Worthington (in


press) as well as questions about core Christian beliefs and salient social issues (e.g., abortion,

same-sex marriage) that cause distress and division amongst Christian subcultures.


Focus: We focused on the assessment of Christian counseling and psychotherapy as practiced by

Christian clinicians. We acknowledge people disagree about defining the terms religiosity and

spirituality. We offer some thoughts.

Spirituality and Religiosity

Religion is commonly thought of in terms of examples of the major world systems such as

Christianity, Islam, Judaism, Hinduism and Buddhism.

Religiosity often refers to the beliefs and practices of an organized religion (Hill et al., 2000).

“Spirituality embodies the most significant values of human life. Those values are expressed in

practices, ways of doing things, beliefs, attitudes, and decisions” (Perrin, 2007, p. 23).

"Spirituality is the universal human capacity to experience self-transcendence and awareness of

sacred immanence, with resulting increases in greater self-other compassion and love" (Cashwell

& Young, 2011, p. 7).

Christian Spirituality (CS)

There are multiple faiths, which influence the expression of CS.

Perrin (2007) observes that there is a growing acceptance that the Christian lifestyle may be lived

out in various ways.


The Importance of Evidenced-Based Psychotherapy (EBP)

Eysenck is famous for his challenge to provide evidence for psychotherapy. The

challenge continues (Wampold, 2013).

Psychotherapists invest considerable resources in preparing to become a psychotherapist

in the belief that they will be able to help clients.

Clients invest considerable resources when they participate in psychotherapy in order to

achieve personal goals.

Society invests considerable resources in behavioral health care.

Researchers find some evidence for hundreds of interventions but the quality of the

evidence varies (Kazdin, 2014).

Researchers find some psychotherapy interventions are harmful or of questionable value

(e.g., Castonguay, Boswell, Constantino, Goldfried & Hill, 2010; Lilienfeld, 2011).

Christian Counseling: What is it?

Although Christian counseling is more than just praying with a client, a "well -articulated,

comprehensive, and integrated approach to Christian counseling does not exist today" (Jones &

Butman, 2011 p. 454). Rather than articulating a working definition of Christian counseling,

Jones and Butman (2011) describe Christian mental health professionals as people who

"manifest and embody biblical truth as they serve those in need of quality mental health services"

(p. 24).


A few explicitly Christian features from the Jones and Butman (2011) list.

a vision of our need for a love relationship with our Creator, attainable only through forgiveness

offered through the death of Jesus Christ

an understanding of the essential place of the work of the Holy Spirit in ultimate healing

an appreciation of the power of sin and evil

an understanding of the influence of the spiritual world on day-to-day human functioning

a respect for individuals that is grounded in God's love for each person yet without worshiping

the individual disconnected from others

a respect for our intrinsically moral natures and the value of obedience to appropriate authority,

preeminently to God and his Word

a love for Christ's body, the church, and a commitment to furthering the church's work in this

world (pp. 453-454).

In our study, we examined various beliefs and practices of self-identified Christian counselors

and psychotherapists.


The Importance of Studying Evidence-Based Christian Accommodative Psychotherapy

(EBCAP)

Clinical experience and professional ethics (e.g., APA) indicate religious-spiritual (RS) issues

are important to clients (Plante, 2009).

Matching religious psychotherapists and clients appears to improve perceived and obtained

outcomes (Worthington, Hook, McDaniel, 2011).

A challenge of integrating religious beliefs into psychotherapy is that the beliefs can be seen as

both helpful and harmful (Rosenfeld, 2010).

Psychotherapist factors make a difference but a Christian factor has not been identified

(Stegman, Kelly, & Harwood, 2013).

Some EBCAPs have been supported by evidence and others show promise but lack

documentation (Worthington, Hook, Johnson, & Aten, 2013).

If they have the option, most couples will choose a faith-friendly intervention (Ripley, Maclin,

Hook, Worthington, 2013).

Hypotheses

1. Most clinicians will include prayer & scripture in treatment sessions

2. There will be a significant positive correlation between the Christian spirituality of

clinicians and the values they hold


clinicians and reported spiritual practices in psychotherapy



clinicians and reported Christian Accommodative Psychotherapies

Additional Research Questions

What specific interventions do Christian Clinicians use?

What might be unique about the spirituality of clinicians or the practice of those who identify as

Pentecostal or Charismatic?

How similar are the beliefs and values of U.S. Christian clinicians to those held by the

population?

METHOD

Participants

General Recruitment: General Christian: CAPS email and Facebook; NACSW posted on list

serve; email to contacts.

Specific Recruitment of Pentecostal/charismatic subsample: Evangel University; AGTS

Sample size: 250 records after removing missing and incomplete records

Age N reporting 188, Mean 46.76 (SD 12.70), Median 47.00


Gender

Gender n Percent

Women 120 47.8

Men 87 34.7

Not reporting 44 17.5

Ethnicity n Percent

European 176 70.1

African 13 5.2

Hispanic 6 2.4

Asian 6 2.4

Other 9 3.6


Christian group affiliation or denomination

Group Identity n Percent

Catholic 8 3.2

Evangelical 82 32.7

Pentecostal/charismatic 48 19.1

Nondenominational 43 17.1

Other 27 10.8


Examples of clinicians in the “other” category: Anglican, Episcopalian, Lutheran, “Mainline,”

Mennonite, Presbyterian, Unitarian,


Primary profession

Profession n Percent

Counselor 99 39.4

Marriage/Family Therapist 31 12.4

Social Worker 10 4

Psychologist 52 20.7

Other 18 7.2


University or professional school degree

Degree n Percent

Masters 110 43.8

MSW 9 3.6

PsyD 24 9.6

PhD 45 17.9

Other 22 8.8



Geographic location of the sample

Location n Percent

East 79 31.5

Central 72 28.7

Mountain 14 5.6

Western 31 15.8

Other 0 0


Measures

• Fundamentalism. We measured two domains of religious fundamentalism (Scripture as

Inerrant and Authoritative using four items (two for each domain) from the original

Intratextual Fundamentalism Scale (Williamson & Hood, 2005). Each item was scored on

a 5-point likert scale from Strongly disagree (1) to Strongly agree (5). The alpha value

was .827 (n = 219), M = 14.73 (SD = 4.08).

• Spirituality Index. The SI is a 12-item measure with three factors common to Christian

Spirituality (Sutton, Jordan, & Worthington, 2014). The Service factor uses three items to

assess activities common to Christian service. The alpha value was .78 (n = 219), M =

11.34 (SD = 2.37). The gift factor focuses on Pentecostal rather than general Christian

views on gifting. Alpha was .71.00 (n = 219), M = 10.55 (SD = 3.76). The Healing factor

consists of 4 items and emphasizes healing from a Pentecostal perspective of divine


intervention. Alpha was .70 (n = 217), M = 13.42 (SD = 3.5). We removed one item about

power from the original scale.

• Christian beliefs

Because we sampled Christian counselors, we created five 5-point likert items rated from

Strongly Agree to Strongly Disagree to assess Christian beliefs that might differentiate

among the respondents. High scores represent strong agreement with traditional Christian

beliefs, which are part of official Christian doctrinal statements. Alpha was .702 (n =

205), M = 23.02 (SD = 2.4).

• Social Issues List. We listed selected contemporary social issues likely to divide clients

and clinicians. Participants were asked to rate their agreement on a 5-point Likert scale.

• Spiritual Interventions and Practices. We asked participants to identify the frequency

of use level in response to spiritual practices and interventions. We included assessment,

general practices, specific interventions, and interventions between sessions. The ratings

ranged from Never to Most of the time.


Results

Christian Beliefs of the Clinicians (Percentages)

Rather than rely on religious affiliation or a simple identity as Christian, we used six belief items,

a measure of fundamentalism, and a measure of spirituality to identify the participants’ Christian

Spirituality.

Belief (n = 251) Strongly Agree/Agree Neither or Disagree No

Response

Jesus is the Son of God 83.7 .4 15.9

Born again experience 78.5 4.8 16.7

God heals w/o human 96.7 3.3 15.9

Christians called to share faith 80.8 3.2 15.9

Clients hell-bound w/o salvation 52.9 29.5 17.5

Jesus as the Son of God is a cardinal Christian belief. Clearly most identify with this belief. The

“born again” item obviously identifies a more modern term used by conservatives. The response

to the “healing item” was surprising yet relevant for a Christian clinician. The notion of sharing

faith is common to Evangelicals. National surveys include questions about heaven and hell. We

considered the hell item likely to identify those with close to a literal view of the Bible.

Christian Fundamentalist Scale: Beliefs of the Clinicians about Sacred Writing (SW)

Belief (n = 251) Strongly

Agree/Agree

Neither or

Disagree

No

Response

SW absolutely true 63.7 24 12.4

SW some contradictions/ errors 30.5 61 12.4

SW never doubt 45.2 42.8 12

If SW disagrees w/ findings then science

probably true

7.7 79.9 12.4


The Other group scored significantly lower on fundamentalism than the other three (Evangelical,

Pentecostal/Charismatic, Nondenominational) F (3, 215) = 7.70, p < .001, eta = .10. The belief

item mostly highly correlated with the fundamentalist scale total was the belief that clients

without salvation are hell-bound (n = 205, r = .584, p <.001). This finding lent support to

including the item when assessing the spirituality of Christian clinicians.

Christian Spirituality of the Clinicians: Three Spirituality Factors

Christian Service: All groups were similar p > .05

Charismatic Gifts: Not surprisingly, only the Pentecostal/Charismatic group reported

significantly more charismatic gifts as part of their spirituality. F (3, 215) = 20.38, p < .001, eta =

.22

Healing: The groups were similar overall (p > .05) with a tendency for Pentecostal/Charismatics

to report a higher level than evangelicals (p = .06) but not more than the other groups.


Values of Christian Clinicians and Contemporary Social Issues

Social issue n Disagree Neither Agree

Birth control: Always sinful 213 92.49 5.63 1.88

Birth control: ok if not abortifacient 213 5.63 10.80 83.57

Abortion: Always sinful 212 34.91 17.45 47.64

Abortion: ok risk harm 212 17.45 26.89 55.19

Abortion: ok rape/incest 213 47.89 29.11 23.00

Premarital sex: Always sinful 212 15.57 9.43 75.00

Cohabitation: Always sinful 213 21.13 17.84 61.03

Marriage: 1 man, 1 woman 213 6.57 8.45 84.98

Marriage: Man is head 213 26.29 21.13 52.58

Divorce is sin 212 25.00 29.25 45.75

Sex orientation is a choice 213 46.01 23.94 30.05

Same sex marriage sinful 212 16.51 17.45 66.04

Women should not be clergy 212 71.23 12.26 16.51

Women- no authority over men 213 69.48 13.15 17.37

Women counsel women & men

counsel men

213 70.89 18.78 10.33

Several social issues divide Christians in the United States. Laws and organizational policies are

changing in matters of birth control, abortion and same-sex relationships. As a social issue,

divorce is somewhat dated but it is still relevant to an understanding of marriage issues. Finally,

women in several faith traditions have limited roles. In most traditions, women are not permitted

to be priests or serve as senior clergy. Some do not permit a woman to be in a position of

authority over a man. And a number of conservative Christian organizations prefer that women

counsel women and men counsel men.


Spiritual Interventions and Practices

We have four sets of tables that summarize how often Christian clinicians use various

interventions and practices. Assessment is an intervention.

Interventions 1: How do Christian Clinicians Assess Spirituality?

Method n Common Never Rarely Sometimes Often Most

1 Interview 240 91.25 4.17 4.58 18.75 24.58 47.92

2 Attendance 238 78.99 8.40 12.61 25.63 24.37 28.99

3 Intake form 242 64.05 32.23 3.72 6.61 4.96 52.48

4 Questionnaires 241 27.39 54.36 18.26 13.28 4.98 9.13

5 Ask spiritual gifts 239 23.01 52.30 24.69 18.83 3.35 0.84

6 Ask fruitful life 239 16.74 62.34 20.92 15.06 0.84 0.84

By far, the most common method of assessing spirituality is during an interview. Asking about

attendance at religious services and getting information on an intake form are also common

methods. Clinicians rarely or never use questionnaires or ask specific questions about the fruits

of the spirit or spiritual gifts.


Interventions 2: What spiritual practices do Christian clinicians use in sessions?

(Percentages)

This list of interventions includes spiritual practices some Christians use or request when in

need. In some cases, we expanded a common practice like prayer so we could obtain more detail.

Spiritual practice Commo

n

Never Rarely Sometimes Often Most

1 Refer to Bible 74.4 6.80 18.80 46.00 17.20 11.20

2 Invite God’s presence 65.67 21.89 12.45 21.89 15.88 27.90

3 Pray about issues 55.42 18.47 26.10 28.51 13.65 13.25

4 Share testimony 58.06 14.92 27.02 41.94 10.48 5.65

5 Spiritual imagery 54.22 16.47 29.32 36.95 13.65 3.61

6 Pray for healing 42.17 26.91 30.92 27.31 8.03 6.83

7 Pray with hands on client 16.94 63.71 23.79 9.68 1.61 5.65

8 Anoint clients oil 3.21 90.76 6.02 2.41 0.40 0.40

9 Pray in tongues 2.01 94.78 3.21 1.61 0.40 0.00

10 Pray for deliverance 5.65 82.26 12.10 3.63 1.61 0.40

11 Prayed to saint 2.80 96.40 0.80 1.20 0.80 0.80

The spiritual practices in rows 1 – 5 are in common use as defined by at least 50% of Christian

clinicians using a practice at least sometimes. As expected, references to the Bible and prayer

were the most frequent spiritual practices employed by Christian clinicians in a session. Prayer

for healing was by no means rare at 42% engaging in this type of prayer at least sometimes.

Considering the responses for more than sometimes, it is possible for clients to visit most

clinicians in our sample and not experience any of the spiritual practices in this list. Practices

generally considered unique to Pentecostal or Charismatic spirituality were rare (e.g., praying in

tongues, praying for deliverance). Approximately 19% of responses were from clinicians who

self-identified with Pentecostal or Charismatic Christianity.


Interventions 3: What Evidence Based Christian Accommodative Practices do clinicians

use?

This group of interventions includes those that are more formalized than those in the previous

list. Some like Christian PREP and SYMBIS provide clinicians with specific guidance.

Treatment Common Never Rarely Sometimes Often Most

1 Christian CBT 44.40 49.14 6.47 18.97 16.81 8.62

2 Contemplative prayer 35.47 50.00 14.53 22.65 10.26 2.56

3 Pray deliverance 34.33 43.35 22.32 21.46 9.44 3.43

4 Centering prayer 28.21 56.41 15.38 19.66 6.84 1.71

5 Inner healing prayer 23.08 59.40 17.52 15.81 4.27 2.99

6 Forgiveness 20.94 67.66 11.54 12.82 6.41 1.71

7 Hope focused 18.38 75.32 5.98 10.68 5.98 1.71

8 Christian PREP 15.38 75.64 8.97 9.83 4.70 0.85

9 SYMBIS 3.42 91.91 4.70 0.43 2.14 0.85

The column labeled common identifies how common an intervention is based on reports that

clinicians use it is at least sometimes. Close to half use Christian CBT. About one-third use

contemplative prayer and prayers for deliverance from a condition. Other identified interventions

are not in common use. The data do not indicate how common use might be for a specific

problem. For example, clinicians would not be expected to use a forgiveness intervention unless

it was relevant to the client’s presenting problem.


Interventions 4: What do Christian clinicians recommended clients do between sessions

(homework)?

People are used to getting recommendations when they seek treatment. Physicians, nurses, and

therapists offer materials to improve health and well-being outside the office setting. Counselors

and Psychotherapists vary in what they recommend.

Recommendation Common Never Rarely Sometimes Often Most

1 Read Christian literature 78.57 7.14 14.29 42.86 29.41 6.30

2 Pray about issues 76.05 10.92 13.03 36.13 26.47 13.45

3 Daily meditation 65.97 18.07 15.97 39.92 15.13 10.92

4 Read Bible 63.45 13.87 22.69 47.06 10.50 5.88

5 Attend church 62.61 17.65 19.75 36.55 15.97 10.08

6 Spiritual journal 52.10 24.37 23.53 36.97 11.34 3.78

7 Keep prayer journal 43.70 28.99 27.31 33.61 6.72 3.36

8 Centering prayer 38.98 42.80 18.22 26.69 8.05 4.24

9 Seminar / workshop 35.71 32.77 31.51 29.83 3.78 32.77

10 Christian videos 21.85 47.48 30.67 18.49 1.68 1.68

11 Theophostic prayer 11.89 74.89 13.22 10.13 0.88 0.88

Clinicians commonly recommend six spiritual practices for their clients between treatment

sessions. Common is defined by a practice used at least sometimes by 50% or more of the

respondents. The list is ordered by percentage of use. The number responding was 238 for all

items except centering prayer (236) and theophostic prayer (227).


CORRELATIONAL ANALYSES

Given the sample size, common methodology, and similarity of many items, it was not surprising

to find a number of statistically significant correlations between pairs of variables. Clearly, small

correlations despite their statistical significance may be of little practical value. We elected to

report only those values of moderate (.25-.39) to large (> .39) size in the context of our sample

size, which varied in the low to mid-200s (Meyers, Gamst, & Guarino, 2006).

Although we found significant correlations between the various measures of spirituality and the

items of interest, the Fundamentalism Scale provided the strongest relationships (positive and

negative). We found that Christians clinicians we classified as Other were significantly lower on

fundamentalism (than were those in any of the other three groups (Evangelical, Pentecostal

Charismatic, Nondenominational).

The relationship between clinician fundamentalist spirituality and social issues

Social issue n r

Birth control: Always sinful 211 ns

Birth control: ok if not abortifacient 211 .31

Abortion: Always sinful 210 .42

Abortion: ok risk harm 209 -.31

Abortion: ok rape/incest 211 -.37

Premarital sex: Always sinful 210 .56

Cohabitation: Always sinful 211 .41

Marriage: 1 man, 1 woman 211 .62

Marriage: Man is head 211 .50

Divorce is sin 210 .32

Sex orientation is a choice 211 .33

Same sex marriage sinful 210 .51

Women should not be clergy 210 .29

Women- no authority over men 211 .43

Women counsel women & men

counsel men

211 .22


Clinician practices within a session that were at least moderately correlated with

fundamentalist spirituality

Spiritual practice n r

Using Bible verses 219 .39

Prayer for client issues 218 .25

Personal sharing 217 .35

Prayer to a saint 219 -.26

All other correlations were less than our threshold of .25

Clinician recommendations for client homework moderately correlated with

fundamentalist spirituality

Recommended homework/activity n r

Pray between sessions 217 .41

Read Bible 219 .33

Read Christian literature 218 .32

Attend church 217 .30

Watch Christian video 217 .28

Keep Prayer journal 217 .26


DISCUSSION

Christian clinicians are divided into conservative and progressive views on theological beliefs

and social issues.

There were no significant differences on most matters of spirituality among the three groups

identifying as Evangelical, Pentecostal/Charismatic, or Nondenominational.

The items from the Intratextual Fundamentalism Scale were valuable in accounting for the

beliefs and values of the clinicians.

The items from the Intratextual Fundamentalism Scale were valuable in accounting for several

counseling practices of the clinicians.

As expected, most clinicians pray and refer to the Bible during sessions at least sometimes but

not at a high level of frequency.

A few in-session and between session activities are commonly but not necessarily frequently

used by Christian clinicians.

Evidenced based Christian Accommodative Psychotherapies are not highly used but Christian

CBT is not rare.

Not much was known about clinicians from Pentecostal-Charismatic traditions. In our study,

they appear similar in most Christian beliefs and most facets of practice to other Evangelicals

and nondenominational Christians.

The predominance of conservative beliefs and social values among many or our clinicians would

seem to support three hypotheses:

1. Their values are a good fit for most conservative Christian clients, which could enhance

rapport and the ability to convey support and positive regard. An increased use of EBCAPs

would likely improve treatment outcomes for these clients.

2. Their values are not a good fit for Christians who identify with the progressive movement and

mainline Protestant traditions as well as non-Christian clients. We expect many of our clinicians

would have an inner spiritual struggle treating other than conservative Christian clients.

3. Their social values and clinical practices are not consistent with those of fundamentalist

Christians who might expect high uses of biblical references and prayer in all sessions.

Limitations

Convenience sample- mostly from the United States and missing data. We did not ask questions

to identify why clinicians used or did not use various practices or interventions. Most surveys of

this type are limited to volunteers, which introduces a selection bias.


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Appendix A

Our participants offered us many examples of other activities that reveal a rich and varied

approach to Christian counseling. We include a few.

Additional assessment practices

Ask what they know, have read, heard from Bible or sermons that may have a bearing on the

current issue

Ask what has not helped from religious/spiritual perspective & why they think it might not have

helped.

Family religious history

Ask open ended questions about how faith has been a source of strength/pain, about how their

faith affects the current issue, about how they wish their faith impacted their situation...

Ask about time dedicated to prayer

Ask what gives their life meaning

I ask what integrating their faith into the session should look like for them.

Additional in-session practices

I've prayed silently for my client during a session without them knowing.

I pray FOR my patients before each session but do not share with them that I do that.

Spiritual/religious poetry


Additional specific interventions

EMDR techniques while asking for God's help via prayer

"Imagine Jesus in the Chair"

Psychodramatic encounter with God

MALI (Married and Loving It)

Christian accommodative Internal Family Systems

Christian accommodative psychodynamic approach

Rites of the church: baptism, anointing with oil, prayer, communion, reconciliation &

forgiveness

Additional recommendations to supplement therapy

I don't often give assignments of any sort. I might ask a client what they think might help and

have them consider it as an option.

Talk to spiritual leader or peer.

Explore Christian music

Deep breathing and meditation on scripture

Practice mindfulness using Christian theme

I ask my clients to journal; however, I do not specifically request a separate "spiritual" journal.

Healing of Memories (not theophostic prayer)

Evidenced-Based Religious Accommodative Psychotherapy: Practice and Belief

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