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April 2010 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Koszycki, D., Raab, K., Aldosary, F. and Bradwejn, J. "A multifaith spiritually based intervention for generalized anxiety disorder: a pilot randomized trial." Journal of Clinical Psychology 66, no. 4 (April 2010): 430-441.


SUMMARY and COMMENT: This month's article reports a study "designed as a pilot trial to evaluate the acceptability and efficacy of a spiritually based intervention (SBI) for generalized anxiety disorder (GAD)" [p. 432], with the primary hypothesis being that "the SBI would result in significant improvement in core symptoms of GAD, with treatment gains persisting over time" and that "the SBI would be non-inferior to CBT [cognitive-behavioral therapy], a first-line psychological intervention for GAD" [p. 432]. While the focus here is on a specific psychotherapeutic program rather than general pastoral care, this research may be of broad interest to chaplains exploring multifaith interventions and of special interest to mental health chaplains. The study "demonstrate[s] that spiritual care professionals working in a mental health facility could play an important role in the delivery of care to individuals with GAD" and sets up a prospect that "spiritually focused interventions, delivered by suitably trained spiritual care counselors" could be recognized as an effective treatment alternative that in turn could "expand the pool of treatment providers, improve access to care, and foster fruitful collaboration between clergy and mental health professionals in the delivery of mental health care" [p. 439].

A sample of 22 individuals with GAD were randomized into SBI and CBT groups for comparison. With dropouts, full data were collected from 9-member groups. One of the characteristics of these participants was that "[t]he Duke Religion Index…revealed that overall few…were actively involved in organized or non-organized religious practices" [p. 435]. The SBI was carried out in 12 sessions of 50-minutes each, "by a spiritual care counselor working in a mental health facility": namely, co-author Kelley Raab, "an ordained minister who also holds a doctoral degree in the psychology of religion" [p. 432]. The intervention was based upon the book Essential Spirituality: The 7 Central Practices to Awaken Heart and Mind, by Roger N. Walsh, MD. Participants were given a copy of that book and assigned readings each week and asked to practice exercises in it. Walsh's own work purports to be "derived from seven religious traditions (Buddhism, Christianity, Confucianism, Hinduism, Islam, Judaism, and Taoism)" with the exercises in the book "designed to help one cultivate a calm and concentrated mind, emotional and spiritual wisdom, spiritual awakening, positive emotions, ethical living, and generosity and service" [p. 432]. [For more on this book, see Related Items of Interest, below.]

The article provides an outline of the content of the 12 SBI sessions [--see Table 1, p. 433]:

  1. Psychoeducation about generalized anxiety disorder and provide rationale for a spiritual intervention. Discuss goals of treatment.
  2. Introduce meditation techniques. Discuss benefits of developing a calm and peaceful mind.
  3. Responding skillfully to difficult emotions. Explore and learn from painful emotions. Release and transform painful emotions and use them appropriately.
  4. The power of forgiveness in releasing emotional pain from the past. The connection between gratitude and positive emotions.
  5. Being mindful. Understanding the benefits of awareness and the costs of living mindlessly.
  6. Awaken spiritual vision by recognizing the sacred in people, things, and within ourselves. Understanding the transforming power of seeing the sacred in all things.
  7. Attachment can be a source of suffering. Happiness lies in reducing and relinquishing attachments.
  8. Cultivating higher motivation is a central goal of spiritual practice. Our deepest desires are healthy and altruistic.
  9. Unethical living springs from and leads to negative emotional states. Ethical living and treating others as you wish to be treated improves emotional well-being.
  10. Express spirit in action. Cultivate generosity and service to others.
  11. Cultivate spiritual intelligence. Seek wisdom in nature, silence and solitude, and reflect on the nature of life and death. Importance of self-acceptance and relinquishing self-attack and condemnation.
  12. Wrap up and Evaluation. Assessment of treatment goals.

Participants were followed and assessed at 3 and 6 months. Among the results, comparing the SBI to CBT:

This study suggests that a multifaith spiritually focused intervention compares well to a first-line psychological intervention for GAD. Both SBI and CBT produced robust and clinically significant reductions from baseline in symptoms of GAD, including pathological worry, the core feature of the disorder. Both treatments were also effective in decreasing self-report depressive symptoms and improving social adjustment. The only efficacy measure that was not improved with the SBI was intolerance for uncertainty. …Analysis of follow-up data revealed that overall the effects of the SBI was durable. [p. 438]
Though the SBI may not be more effective than CBT, the authors suggest that its comparable efficacy may be significant in that such a treatment option could for some patients "be more appealing and perceived as more holistic or less stigmatizing than conventional treatment for psychiatric disorders" [p. 439]. They also point out that "with growing public interest in spirituality many patients are requesting spiritually integrated care from mental health professionals" and therefore "rigorous evaluation of spiritual interventions that are delivered by appropriately trained spiritual care and mental health professionals is of paramount importance" [p. 439]. This is a small study, but it was conducted with sufficient care to warrant close attention by chaplains and mental health providers.


Suggestions for the Use of the Article for Discussion in CPE: 

This month's article gives students to a chance to think about the idea of a multi-session behavioral health program incorporating a spiritual care provider. It also puts forward one model of a multifaith approach that could be explored beyond the article by reading from the source book: Roger N. Walsh's Essential Spirituality: The 7 Central Practices to Awaken Heart and Mind [--see Related Items of Interest, §1, below]. Students may see in the character of the spiritual intervention elements common to a range of religious traditions but especially associated with Eastern traditions, and this may spark some talk about the often prominent place of Eastern spirituality in multifaith/interfaith interventions in the current healthcare literature. For those students interested in research, the article offers a good illustration of a comparator study, with a longitudinal method being a particularly strong aspect. Finally, this study suggests that a spiritual intervention need not be more effective than others in order to be valuable: its worth could lie in the potential to draw people into therapy who might not otherwise seek treatment. What "bar" must a spiritually based intervention need to pass in order to be considered useful?


Related Items of Interest:

I. Regarding Roger Walsh's Essential Spirituality:

Walsh, R. Essential Spirituality: The 7 Central Practices to Awaken Heart and Mind. New York: John Wiley & Sons, Inc., 1999. [The book is organized around the "Perennial Philosophy" of world religious wisdom, the four elements of this being: 1) there are two realms of reality --i.e., the "everyday" realm and a realm "far more subtle and profound: a realm of consciousness, spirit, Mind, or Tao" [p. 7]; 2) human beings partake of both realms; 3) human beings can recognize their divine spark and the sacred ground that is its source; and 4) realizing our spiritual nature is the highest goal and greatest good of human existence. With these four things in mind, the author explicates what he calls the seven "Perennial Practices":

  1. Transform your motivation: reduce craving and find your soul's desire
  2. Cultivate emotional wisdom: heal your heart and learn to love
  3. Live ethically: feel good by doing good
  4. Concentrate and calm your mind
  5. Awaken your spiritual vision: see clearly and recognize the sacred in all things
  6. Cultivate spiritual intelligence: develop wisdom and understand life
  7. Express spirit in action: embrace generosity and the joy of service
Throughout, Walsh gives strategies for practice and specific exercises. The book contains source notes and a fairly extensive bibliography.]

Walsh, R. "Roger Walsh, MD, PhD. Essential spirituality for healing professionals. Interview by Bonnie Horrigan." Alternative Therapies in Health & Medicine 8, no. 2 (March-April 2002): 76-85. [(Abstract:) Roger Walsh, MD, PhD, was born in Brisbane, Australia, and graduated from the University of Queensland with degrees in psychology, physiology, neuroscience, and medicine. He then came to Stanford University, Stanford, Calif, on a Fulbright scholarship, trained in psychiatry, and obtained clinical licenses in medicine, psychology, and psychiatry. Dr Walsh is currently professor of psychiatry, philosophy, and anthropology at the University of California, Irvine. His recent publications include Paths Beyond Ego: The Transpersonal Vision and Essential Spirituality: The Seven Central Practices to Awaken Heart and Mind, with a foreword by His Holiness the Dalai Lama. Dr Walsh’s research has focused on topics such as meditation, Asian psychologies and philosophies, the nature of psychological health and well-being, transpersonal psychology, spirituality, contemplative disciplines, and the psychological roots of our contemporary global crisis. Alternative Therapies interviewed Dr Walsh in his offices at the University of California, Irvine.]


II. General assessments of spiritually based behavioral health therapies:

Hook, J. N., Worthington, E. L. Jr., Davis, D. E., Jennings, D. J. 2nd., Gartner, A. L. and Hook, J. P. "Empirically supported religious and spiritual therapies." Journal of Clinical Psychology 66, no. 1 (January 2010): 46-72. [This article evaluated the efficacy status of religious and spiritual (R/S) therapies for mental health problems. A total of 24 studies were examined, addressing problems in 8 areas: depression, anxiety, unforgiveness, eating disorders, schizophrenia, alcoholism, anger, and marital issues. The authors assess two therapies as "efficacious": Christian accommodative cognitive therapy (CT) for depression and 12-step facilitation (TSF) for alcoholism; two as "efficacious treatments, combined with medication": Muslim psychotherapy for depression and Muslim psychotherapy for anxiety; six as "possibly efficacious": Christian devotional meditation for anxiety, Taoist CT for anxiety, Christian accommodative group treatment for unforgiveness, spiritual group treatment for unforgiveness, Christian group CBT for marital issues, and Christian lay counseling for general psychological problems; and two as "efficacious treatments, combined with existing inpatient treatment": spiritual group therapy for eating disorders and Buddhist accommodative CT for anger. There is an extensive table -- pp. 50-58 -- outlining the various studies.]

Smith, T. B., Bartz, J. and Richards, P. S. "Outcomes of religious and spiritual adaptations to psychotherapy: a meta-analytic review." Psychotherapy Research 17, no. 6 (November 2007): 643-655. [(Abstract:) The use of spiritually oriented psychotherapies has increased dramatically during the past decade. This article reports a meta-analysis of 31 outcome studies of spiritual therapies conducted from 1984 to 2005 with clients suffering from a variety of psychological problems. Across the 31 studies, the random-effects weighted average effect size was 0.56. This finding provides some empirical evidence that spiritually oriented psychotherapy approaches may be beneficial to individuals with certain psychological problems (e.g., depression, anxiety, stress, eating disorders). Recommendations for future research in this domain are offered.]


III. Other Recent Articles of Interest:

Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C. and Haglin, D. "Mindfulness-based cognitive therapy for generalized anxiety disorder." Journal of Anxiety Disorders 22, no. 4 (May 2008): 716-721. [(From the abstract:) While cognitive behavior therapy has been found to be effective in the treatment of generalized anxiety disorder (GAD), a significant percentage of patients struggle with residual symptoms. There is some conceptual basis for suggesting that cultivation of mindfulness may be helpful for people with GAD. Mindfulness-based cognitive therapy (MBCT) is a group treatment derived from mindfulness-based stress reduction (MBSR) developed by Jon Kabat-Zinn and colleagues. MBSR uses training in mindfulness meditation as the core of the program. MBCT incorporates cognitive strategies and has been found effective in reducing relapse in patients with major depression.... Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 6, 615-623). METHOD: Eligible subjects recruited to a major academic medical center participated in the group MBCT course and completed measures of anxiety, worry, depressive symptoms, mood states and mindful awareness in everyday life at baseline and end of treatment. RESULTS: Eleven subjects (six female and five male) with a mean age of 49 (range=36-72) met criteria and completed the study. There were significant reductions in anxiety and depressive symptoms from baseline to end of treatment. CONCLUSION: MBCT may be an acceptable and potentially effective treatment for reducing anxiety and mood symptoms and increasing awareness of everyday experiences in patients with GAD. Future directions include development of a randomized clinical trial of MBCT for GAD.]

Paukert, A. L., Phillips, L., Cully, J. A., Loboprabhu, S. M., Lomax, J. W. and Stanley, M. A. "Integration of religion into cognitive-behavioral therapy for geriatric anxiety and depression." Journal of Psychiatric Practice 15, no. 2 (March 2009): 103-112. [(Abstract:) Religion is important to most older adults, and research generally finds a positive relationship between religion and mental health. Among psychotherapies used in the treatment of anxiety and depression in older adults, cognitive-behavioral therapy (CBT) has the strongest evidence base. Incorporation of religion into CBT may increase its acceptability and effectiveness in this population. This article reviews studies that have examined the effects of integrating religion into CBT for depression and anxiety. These studies indicate that improvement in depressive and anxiety symptoms occurs earlier in treatment when CBT incorporates religion, although effects are equivalent at follow-up. The authors present recommendations for integrating religious beliefs and behaviors into CBT based on empirical literature concerning which aspects of religion affect mental health. A case example is also included that describes the integration of religion into CBT for an older man with cognitive impairment experiencing comorbid generalized anxiety disorder and major depressive disorder. It is recommended that clinicians consider the integration of religion into psychotherapy for older adults with depression or anxiety and that studies be conducted to examine the added benefit of incorporating religion into CBT for the treatment of depression and anxiety in older adults.]



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