Cognitive Behavioral Therapy for Christians with Depression : A Practical Tool-Based Primer 9781599474922, 9781599474915

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Cognitive Behavioral Therapy for Christians with Depression

Cognitive Behavioral Therapy for Christians with Depression A Practical Tool-­Based Primer

= Michelle Pearce, PhD

TEMPLETON PRESS

Templeton Press 300 Conshohocken State Road, Suite 500, West Conshohocken, PA 19428 www.templetonpress.org © 2016 by Michelle Pearce All rights reserved. No part of this book may be used or reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the written permission of Templeton Press. Unless otherwise indicated, all Scripture quotations are taken from the Holy Bible, New International Version®, NIV®. Copyright ©1973, 1978, 1984, 2011 by Biblica, Inc.™ Used by permission of Zondervan. All rights reserved worldwide. www.zondervan.com The “NIV” and “New International Version” are trademarks registered in the United States Patent and Trademark Office by Biblica, Inc.™ Scripture quotations from THE MESSAGE. Copyright © by Eugene H. Peterson 1993, 1994, 1995, 1996, 2000, 2001, 2002. Used by permission of NavPress. All rights reserved. Represented by Tyndale House Publishers, Inc. Scripture quotations marked The Living Bible are taken from The Living Bible copyright © 1971. Used by permission of Tyndale House Publishers, Inc., Carol Stream, Illinois 60188. All rights reserved. Scripture quotations marked (NLT) are taken from the Holy Bible, New Living Translation, copyright ©1996, 2004, 2007, 2013, 2015 by Tyndale House Foundation. Used by permission of Tyndale House Publishers, Inc., Carol Stream, Illinois 60188. All rights reserved. Scripture quotations marked (AMP) are taken from the Amplified® Bible (AMP), Copyright © 2015 by The Lockman Foundation. Used by permission. www.Lockman.org. Scripture labeled KJV is from the Holy Bible: King James Version. Designed and typeset by Gopa & Ted2. Inc. Library of Congress Cataloging-in-Publication Data Names: Pearce, Michelle, 1977- author. Title: Cognitive behavioral therapy for Christians with depression : a practical tool-based primer / Michelle Pearce, PhD. Description: West Conshohocken, PA : Templeton Press, [2016] | Includes bibliographical references and index. Identifiers: LCCN 2016021815 (print) | LCCN 2016023830 (ebook) | ISBN 9781599474915 (paperback) | ISBN 9781599474922 (ebook) Subjects: LCSH: Depressed persons—Pastoral counseling of. | Depressed persons—Counseling of. | Depressed persons—Religious life. | Depression, Mental—Religious aspects— Christianity. | Psychotherapy—Religious aspects—Christianity. | Cognitive therapy. | BISAC: PSYCHOLOGY / Mental Health. | RELIGION / Christian Ministry / Counseling & Recovery. | PSYCHOLOGY / Cognitive Psychology. Classification: LCC BV4461 .P43 2016 (print) | LCC BV4461 (ebook) | DDC 616.85/270651—dc23 LC record available at https://lccn.loc.gov/2016021815 Printed in the United States of America 16 17 18 19 20 10 9 8 7 6 5 4 3 2 1

This book is dedicated to my clients: Your courage inspires me. Thank you for the honor of walking a part of your journey with you.

Contents

Foreword ix Preface xiii Acknowledgments xv Part One: Overview of Christian Cognitive Behavioral Therapy Chapter 1: Why Integrate Religion into Therapy?

3

Chapter 2: Assessment

19

Chapter 3: Introducing the CCBT Treatment Model to Your Client

33

Part Two: Seven Practical CCBT Treatment Tools Chapter 4: Renewing Your Mind: Planting Truth

45

Chapter 5: Changing Your Mind: Metanoia

61

Chapter 6: Finding God and the Blessing in Suffering: Redemptive Reframing

81

Chapter 7: Reaching Out and Connecting

99

Chapter 8: Letting Go and Letting God: Acceptance and Forgiveness

115

viii | contents

Chapter 9: Saying Thanks: Gratitude

135

Chapter 10: Giving Back: Service

151

Chapter 11: Conclusion and Relapse Prevention

169

Appendix A: For Clergy

177

Appendix B: CBT and Christian CBT Resources

181

Appendix C: Reproducible Resources

187

Notes 199 References 207 About the Author

219

Index 221

Foreword

I

t was the fall of 2010. My colleague Dr. Michael B. King and I were ready to submit a 122-­page research proposal for funding consideration to the John Templeton Foundation. We wanted to conduct a large randomized clinical trial to study the effectiveness of religious cognitive behavioral therapy (CBT) for the treatment of depression in persons with chronic medical illness. The idea for this study came from the work of Dr. Rebecca Propst (who had examined the effects of religious CBT and found it as or more effective than secular CBT for depression nearly twenty years earlier) and a report by Dr. King’s group on the effectiveness of online CBT in the treatment of depression in primary care. Other researchers had been finding that the majority of psychotherapy patients wish to have their religious beliefs considered and utilized in their psychotherapy. This approach, however, was seldom taken. Religious patients, concerned that secular therapists were not considering or even respecting their beliefs, often sought help from clergy rather than a mental health professional. This was true even for people with severe depression who needed expert psychiatric care. As such, we felt fairly confident that a religiously integrated treatment—CBT, in this case—would be preferred and at least as effective as standard secular treatment for persons with depression. We thought this would especially be true for those who were religious and for those with chronic illness, where difficulties in coping with the illness, not genetic or primary biological factors, were

x | foreword

driving their depression. The only problem was that the treatment we were proposing had not yet been adapted to the needs of those with chronic medical illness or been tested using a remote delivery method (by telephone, Skype, or online). The latter was particularly important to facilitate the treatment of those with chronic illness who had a difficult time making it into therapists’ offices. I contacted Dr. Propst in Oregon and Dr. Joseph Ciarrocchi at Loyola University in Maryland to help us develop a manualized version of religious CBT. We had barely gotten started with the manual when health problems prevented Dr. Propst from continuing and Dr. Ciarrocchi unexpectedly passed away. Then I frantically set up a meeting with Dr. Pearce with the hope that she would help us develop a religiously integrated CBT that could be administered to individuals from diverse religious groups (Buddhists, Christians, Hindus, Jews, and Muslims). After enthusiastically agreeing, Dr. Pearce took over the lead in writing the manual for the Christian version of our religiously integrated CBT (and helped to adapt it to other religious traditions). She later trained and supervised the therapists who provided this treatment in our randomized clinical trial. Over the next four and a half years, we faced our fair share of hurdles completing this complex, multisite study. On one particularly trying day, I remember making a tongue-­in-­cheek remark to Dr. Pearce that her first book should be about this study—on how to survive a clinical trial! I’m delighted that she took up the challenge and picked an even better topic on which to write. In this primer, the fruit of our labors is packaged in such a way that clinicians and their Christian patients can benefit from what we learned—the ultimate goal for conducting this research. In my opinion, Cognitive Behavioral Therapy for Christians with Depression: A Practical Tool-­Based Primer is a must-­have guidebook for mental health professionals and pastoral counselors who want to help Christian clients use their faith as a healing resource in psychotherapy. In the following pages, practitioners will learn the helpful (and sometimes not-­so-­helpful) role a person’s Christian faith can

foreword | xi

play in psychotherapy. They will be equipped to discuss religious issues and use religiously integrated tools in their work. The seven practical tools and skill-­building activities outlined in this primer are now supported by scientific evidence, which Dr. Pearce summarizes at the beginning of each chapter. She also provides suggested dialogue to aid therapists in introducing the concepts and tools, as well as many case examples that bring the seven Christian CBT (CCBT) tools to life. Clergy will also benefit from reading this primer. They will learn how Christianity can be integrated into an evidence-­based secular mental health treatment for depression, which is sure to increase their comfort level for making referrals to mental health practitioners who provide this form of treatment. It will also help clergy better educate their congregants about religiously integrated psychotherapy and the need to seek professional help when experiencing symptoms of depression. Individuals who are seeking a Christian approach to psychotherapy will be happy to know that not only is such an approach available but that it has scientific evidence supporting its effectiveness. I think there is no wiser investment of a therapist’s or clergyperson’s time than reading this book and practicing the tools that it contains. The result will be that Christian patients with depression will not only lessen their suffering but will also strengthen and deepen their faith. Harold G. Koenig, MD Professor of Psychiatry and Behavioral Sciences Associate Professor of Medicine Director, Center for Spirituality, Theology and Health Duke University Medical Center Durham, North Carolina

Preface

I

n the pages to come, I will suggest that we need to know how to integrate religion into psychotherapy in part because none of us—neither therapists or clients—come to therapy free of values or morals. It seems fitting, then, in the interest of full disclosure that I share a little about my background and why I was delighted when Templeton Press approached me to write this book. For as long as I can remember, I have been fascinated by the role that religion plays in people’s lives, particularly how it appears to help people navigate challenging life circumstances. Not until I began my doctoral studies in clinical psychology at Yale University did I discover that it was possible to study religion empirically. Until then, as a Christian woman, religion had been a matter of faith, not science. Since my first semester in graduate school, I have worked with brilliant colleagues across the nation to scientifically study the role religion plays for cancer patients and their caregivers at the end of life, for teenagers who are depressed, for children who witness and/ or experience violence, and for adults with depression, HIV, addictions, sickle cell disease, or chronic pain. The data from these studies are consistent with what other researchers have found: People who experience mental or physical health problems, or both, frequently rely on their faith to cope, and for many of them this leads to greater well-­being and less distress. However, I also learned that a number of people experience spiritual struggles, and when they do, they also tend to have greater depression and anxiety.

xiv | preface

After I completed my internship in the Cognitive Behavioral Therapy (CBT) and Health Psychology track at Duke University Medical Center, I stayed on to complete two postdoctoral fellowships, one in CBT at the Duke Cognitive Behavioral Research and Treatment Program, and one in religion and health with the Duke Center for Spirituality, Theology, and Health, directed by Dr. Harold Koenig. After my fellowship I was hired on as faculty at Duke and was licensed to practice psychology. Soon after, I was given the honor of working with Dr. Koenig to design a treatment manual and accompanying patient and therapist workbooks for integrating Christianity into CBT for the treatment of depression among the medically ill. This assignment was the ideal blending of my training experiences, skill set, and interests in mental and physical health, psychotherapy, and religion. Psychologists who are experts in other major world religions helped us adapt the Christian CBT manual for Judaism, Islam, Buddhism, and Hinduism. (All manuals and workbooks are available on the Duke Center for Spirituality, Theology, and Health website.) Then our team, led by Dr. Harold Koenig and Dr. Michael King, tested the effectiveness of religiously integrated CBT versus conventional CBT for the treatment of depression in a multisite, randomized controlled trial funded by the John Templeton Foundation. This primer describes the major tools and concepts we used in the ten-­session manualized Christian CBT treatment. I have also added numerous case studies exemplifying the use of the tools, as well as an educational component based on findings from the scientific literature, neither of which is available in the manuals. My hope is that this primer is an accessible, informative, and practical resource for mental health practitioners and pastoral counselors who want to integrate their clients’ Christian faith into the treatment they provide. Ultimately, my greatest desire in writing this book was to provide Christian clients struggling with depression the means to an effective psychological treatment that supports their faith in a divine source of peace and healing. —Michelle Pearce

Acknowledgments

A

book is never a solitary endeavor, and this one would not have been possible without the contributions of the following individuals. Thank you to my mentor, colleague, and friend, Dr. Harold Koenig, who has had the single largest significant impact on my career. It is a privilege working with you. Thank you to the research teams at Duke University Medical Center and Glendale Adventist Medical Center and the study therapists and consultants. Your hard work and relentless dedication allowed us to empirically test and disseminate religiously integrated CBT to treat depression. Finally, thank you to the clients who participated in the intervention study and those with whom I have worked in my clinical practice. You have taught me so much about why and how to integrate religion into psychotherapy.

Part One Overview of Christian Cognitive Behavioral Therapy

Chap t er 1

Why Integrate Religion into Therapy?

C

lients bring a powerful healing resource into our offices every day, yet few of us know it, let alone use it to help them recover. Most of us don’t realize that this valuable resource has the potential to create a strong therapeutic alliance early on, promote engagement with treatment, and increase our clients’ likelihood of experiencing positive change. For those of us who do know about this resource, few have received training on how to integrate it into treatment. It’s time for a change. You’ve probably gathered from the title of this book that I’m going to say that this healing resource is religion. If so, you’re correct, but you don’t need to take my word for it. An accumulating body of scientific research shows that our clients’ religious beliefs, practices, and resources can have the positive and powerful impact described above when integrated into psychotherapy.

Does Religion Belong in Psychotherapy? I hear this question a lot from mental health practitioners. Here’s my short answer: If religion is important to our clients, religion will be part of psychotherapy whether we discuss it or not. I say this because clients can’t check their worldview, spirituality, or values at our door any more than we can choose to leave our hands and feet behind when we go to work. A religious identity and worldview are integral aspects of how religious clients think about, experience, respond to, and take action upon their world, which makes for a good chance that their religious faith is a lens through

4 | overview of christian cognitive behavioral therapy

which they view their experience of depression and recovery. If we don’t discuss their religious beliefs and worldview, we may be missing vital information and a significant way of improving their psychological well-­being. So, to me, the question isn’t really, “Does religion belong?” but rather, “How can we help our religious clients engage with and use their faith as a healing resource in psychotherapy?” This book is my attempt to answer this important question. Research shows that the majority of our religious clients want us to discuss their religious beliefs and practices with them. In a national poll of one thousand Americans, 83 percent said their religious beliefs and emotional health were closely related, and 72 percent preferred to see a therapist who respected and integrated their religious beliefs into therapy.1 Other researchers have found that between 53 percent and 77 percent of clients want to have a discussion about religious and spiritual issues with their therapist.2 In fact, the more religious a client is, the more likely she or he will want religion to play a role in therapy.3 Other research shows that clients think that therapists who integrate religion and spirituality are more competent than those who do not.4 You might have noticed that there is a long history of antagonism between psychology and religion, despite both being healing traditions. Fortunately, things are starting to shift, as practitioners of each tradition see that together they might provide an even more powerful healing force for those in need. For example, of 153 American marital and family therapists surveyed, 72 percent believed that spirituality is relevant to clinical practice, and 54 percent wanted to learn ways to assess for and integrate spirituality into treatment.5 Similarly, in a recent survey completed by 262 members of the Association of Behavioral and Cognitive Therapists, 96 percent reported that religious and spiritual issues are “sometimes” to “always” relevant to mental health, and 64 percent were “mostly” to “very much” interested in receiving further training in this area.6 However, another survey found that only 30 percent of psychologists discussed religion and spirituality with their clients.7

why integrate religion into therapy? | 5

What we see from the literature is that the majority of therapists and clients are answering the question, “Does religion belong in psychotherapy?” with a resounding “Yes!” But many mental health professionals aren’t taught how to engage with religious issues in therapy, meaning that this resource for our clients often goes unnoticed and untapped. That’s one of the reasons I think we really should be examining the question, “How can we help our religious clients engage with and use their faith as a healing resource?” To answer this question, we as mental health practitioners first need to know the benefits of addressing our clients’ faith in psychotherapy. Then we need an organizing therapeutic approach and a set of practical tools to enable us to integrate religion effectively into treatment, and that’s what this book is designed to provide. Below, I’ve tried to anticipate the questions you might have about integrating religion in psychotherapy. As I attempt to provide answers, I’ll say more about the benefits of incorporating our clients’ religious beliefs and practices in therapy, and will introduce a therapeutic approach that helps us do just that.

If I’m Treating Depression, Why Do I Need to Know about Religion? Let’s take a look at some statistics to help answer this question. First, a little about depression, which is a serious public health problem. It’s the leading cause of disability worldwide, and national surveys reveal an alarming prevalence of depression in the United States. Every year, 25 million Americans experience symptoms severe enough to warrant a diagnosis of depression. That’s almost equivalent to the entire population of Texas! Twenty-­five percent of women and 10 percent of men will experience an episode of depression in their lifetime. Sadly, more than half of these individuals will go on to experience at least one more episode of depression. If you’re in clinical practice, no doubt you have worked with many individuals experiencing depression. National polls also reveal that America is a religious nation.

6 | overview of christian cognitive behavioral therapy

Seventy-­nine percent of Americans consider themselves affiliated with a religion, 93 percent believe in God or a higher power, and 77 percent consider themselves to be religious.8 Although the United States is a religiously diverse nation, and is becoming more so each year, the majority of Americans—77 percent—consider themselves Christian.9 Put these two sets of statistics together, and the chances are excellent that we will treat, and have already treated, Christian clients who are depressed. At one time we might have considered religion to be just another descriptive fact about our clients, such as “buys Apple products” or “votes liberal”—a descriptive fact that we considered interesting, but not necessarily relevant to therapy. However, research shows that religious involvement is more than demographic information; it is related to our clients’ treatment of and recovery from depression. A large body of scientific work conducted by researchers worldwide has revealed a relationship between religion and depression. Between 1962 and 2011, at least 444 studies examined this relationship.10 Of these studies, 60 percent reported that the more religious individuals are, the less likely they are to be depressed, and if they do become depressed, they tend to recover more quickly. Among the 178 highest-­quality studies, the number reporting this inverse relationship goes up to 67 percent. Only 6 percent of the studies reported greater depression among the more religious. Greater religiousness may be associated with less depression for many reasons. Religion can help people cope with stress, buffer the effects of challenging life events, and offer a framework for meaning and purpose, particularly for circumstances that seem senseless and beyond our control.11 Religious individuals are also often part of a religious community, and the social support received may help prevent the development of depression or speed its recovery. We also need to acknowledge that religion is not always a source of healing and positive feelings. Christians can experience struggles in their relationship with God and members of their religious community and have other faith-­related struggles, all of which can result

why integrate religion into therapy? | 7

in sadness, distress, doubt, fear, and guilt. Spiritual struggles, such as feeling punished or abandoned by God, can cause and worsen psychiatric symptoms,12 just as psychiatric symptoms can cause and exacerbate spiritual struggles. In one survey of 2,754 clients across the United States, 20 percent endorsed clinically significant levels of religious or spiritual distress.13 As such, it is important for therapists to know how to assess for and engage with clients regarding spiritual struggles. We look in more detail in the following chapters at the scientific literature demonstrating the relationship between religious beliefs and practices and depression. What we see from this brief overview is that religious beliefs, practices, values, and coping styles matter in the development and treatment of depression. One more important reason to know about religion if we are treating depression is that our ethical practice codes mandate it. For example, the ethical codes of both the American Psychological Association (APA) and the American Counseling Association (ACA) state that religion is a domain of diversity that requires clinical competence.14 The APA’s Board of Ethnic and Minority Affairs state their guideline as follows: “Psychologists respect clients’ religious and/or spiritual beliefs and values, including attributions and taboos, since they affect worldview, psychosocial functioning, and expressions of distress.”15 Social workers are also mandated to demonstrate cultural competence, which includes using interventions that are relevant and sensitive to their clients’ worldview.16 These ethical codes suggest that respecting our clients’ religion requires more than just being aware that they are religious. We need to be intentional about knowing how our clients’ religion impacts how they view their world and function in it, as well as how it impacts their experience of and recovery from depression. Just like other domains of diversity, such as gender, ethnicity, or race, to achieve competency we need knowledge, understanding, and ongoing training. Learning how to integrate religion into psychotherapy

8 | overview of christian cognitive behavioral therapy

is one way of working toward this required competency. In sum, as these statistics and practice guidelines demonstrate, we cannot ignore religion when we think about and treat depression.

Does Talking about Religious Beliefs and Practices in Therapy Actually Help Alleviate Depression? This question is a valid one. Just because many clients want to talk about religion during treatment doesn’t necessarily mean that doing so helps reduce their symptoms of emotional distress. This empirical question requires rigorous science and data from multiple studies to answer properly. Thankfully, a number of researchers around the globe have been interested in determining the answer to this question. Over the last two decades, more than fifty studies have been conducted to test the effectiveness of therapies that integrate clients’ religious and spiritual beliefs. In these studies, various forms of psychotherapy were modified to include religious and spiritual themes, discussions, imagery, sacred texts, and in some cases, prayer. Although the studies vary in their design and rigor, overall the results suggest that talking about clients’ religious beliefs and practices during treatment helps to reduce symptoms of emotional distress. The majority of empirical studies have demonstrated that spiritually integrated therapies are at least as effective, if not more effective, in reducing depression and anxiety than is traditional, nonreligious therapy for religious clients.17 A team of researchers, led by Dr. Everett Worthington at Virginia Commonwealth University, analyzed data from forty-­six studies on spiritually integrated therapy published before the end of 2009.18 This meta-­analytic review revealed that religious clients receiving spiritually integrated therapies showed more improvement in psychological as well as spiritual outcomes compared to those who received alternate psychotherapies. When they compared spiritually integrated therapy to the same type of therapy in secular form, clients receiving the spiritually integrated form of therapy had greater improvement in spiritual

why integrate religion into therapy? | 9

outcomes and similar improvement on psychological outcomes. Thus, psychotherapy that integrates clients’ religious and spiritual beliefs can be of benefit for both their psychological health and their spiritual health. In other words, psychotherapy for Christian clients can be more than just nonthreatening to their identity as a Christian; it can serve as a means of growing their faith, religious identities, and spiritual well-­being, which are woven together with emotional well-­being, as we have seen. Of greatest relevance to the tools provided in this book are the empirical data demonstrating the effectiveness of Christian cognitive behavioral therapy (CBT). In some studies, Christian CBT (also referred to as CCBT) was more effective in reducing symptoms of depression than was nonreligious CBT.19 In other studies, Christian CBT was equally as effective as conventional CBT for treating depression,20 and more effective than a control group.21 In our multisite randomized controlled trial (with primarily Christian clients), we found that religiously integrated CBT was as effective as conventional CBT in reducing symptoms of depression immediately after treatment (twelve weeks) and also three months later, and was most effective in individuals who were more religious.22 We also found that religiously integrated CBT improved positive outcomes, such as gratitude, altruism, and purpose in life.23 Cumulatively, this body of research demonstrates that Christian CBT meets the American Psychiatric Association’s criteria for a well-­established, empirically validated treatment for depression.24

Isn’t This What Clergy Do? Why Not Just Refer? There are several important distinctions between counsel provided by clergy and psychotherapy practiced by mental health professionals and licensed pastoral counselors. Given these differences, a referral to clergy may or may not be the best treatment choice for our clients. There are a number of factors that make it more difficult for

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certain groups of people to participate in mental health services. Religion can be one such factor. Some religious individuals feel that secular therapists won’t understand or respect their religious beliefs, or at least are not interested in hearing about them. When I ask clients about the role and importance of religion in their lives, I’ve had many look at me in wonder and whisper, “Can I really talk about that here?” Even when given “permission” to talk about issues related to their religious identity, it can be easier for them to discuss the abuse they were subjected to during childhood than to share that they are now feeling distant from God and how much this condition upsets them. Still others have been taught that “good Christians” don’t get depressed, a damaging message that incites much guilt and shame and unnecessarily prolongs suffering. Equally damaging is the belief that seeking secular treatment means a person doesn’t have enough faith in God or is somehow abandoning the faith, as if faith and psychotherapy are mutually exclusive. Still others fear that secular therapy will erode their faith.25 Unfortunately, as mental health professionals, we have been guilty of communicating these messages, if not directly then indirectly, by the invitations we haven’t extended to our religious clients to disclose and explore their faith with us. Perhaps as a result of these barriers, Christian individuals are more likely to seek support from clergy than from mental health professionals,26 which is particularly true for individuals who are Hispanic or African American.27 Almost one-­quarter of individuals receiving counseling from clergy have a serious mental disorder, and most of these people are not also under the care of a mental health professional or physician.28 The concern here isn’t that clergy aren’t helpful or supportive; rather, clergy are not typically trained to diagnose or treat mental health disorders. Instead, clergy and spiritual leaders are trained in theology and church ministry. They offer sound theological knowledge, support, advice, and play an important role in individuals’ spiritual development and discipleship, a role that mental health professionals are not trained or equipped to play.

why integrate religion into therapy? | 11

Mental health professionals (psychologists, psychiatrists, social workers, licensed counselors, marriage and family therapists, et al.), on the other hand, are trained to diagnose mental health disorders using the Diagnostic and Statistical Manual of Mental Disorders (DSM) and to administer empirically validated psychotherapeutic interventions to treat these disorders. Decades’ worth of empirical data have been collected to support various psychological treatments, and more data is generated every year as new therapies are developed and older ones are refined. Licensed pastoral counselors usually have training in both mental health and religion. Those certified by the American Association of Pastoral Counselors (AAPC)—the gold standard in this field— have a postgraduate degree from an accredited university, experience and training in ministry, a relationship with a local religious community, and hold a state license as a social worker, marriage or family counselor, or psychologist. (To simplify the language used throughout this book, I include certified pastoral counselors who meet the AAPC criteria under the term mental health professionals.) Let me be clear. Neither mental health professionals nor clergy are better in merit than the other. Rather, each profession is better suited and trained for certain issues and maladies. Mental health professionals need to stay within their limits of training (i.e., assessment, diagnosis, and psychotherapeutic interventions) and not give religious or theological advice or opinions. Likewise, clergy need to practice within their training (e.g., spiritual direction, theological discussions, and biblical exegesis) and not engage in therapy. When we put our expertise together, we make a powerful healing team. Unfortunately, we consult with and make referrals to one another infrequently.29 In summary, to answer the question posed above, a Christian individual who is suffering from depression, as defined by the DSM, needs an evaluation and mental health treatment provided by a licensed mental health care provider. That being said, clergy can and should play an integral role in the client’s spiritual care, as well as offer valuable contributions through consultation and

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collaboration with the mental health care provider. (For clergy who would like more information on symptoms of depression and on making a referral, see appendix A.) As mental health professionals, we have the responsibility of reducing the barriers that religious individuals may face in seeking and receiving psychotherapy. We need to know how to provide care that is sensitive to our Christian clients’ worldview and value system. By using the religiously integrated CBT tools and principles in this book, which are supported by empirical research, we can feel confident that what we are offering is sound psychological treatment sensitive to our Christian clients’ needs.

What If I Don’t Know Much about Religion, Let Alone How to Integrate It into Therapy? You wouldn’t be alone. The majority of doctoral programs and predoctoral internships don’t provide clinical training in religious and spiritual issues.30 In a sample of 262 CBT practitioners, 71 percent reported receiving little to no clinical training in addressing religious or spiritual issues in psychotherapy.31 As the researchers remarked, this might explain why 36 percent of them reported some discomfort discussing religious or spiritual issues in treatment. It may also help to explain why another group of researchers found that clients are usually the ones to initiate discussions about religious issues in therapy.32 Not helping matters is that psychologists and psychiatrists are traditionally less religious than the population they serve.33 ­Overall, they are less likely to believe in God, pray, and attend religious services, and are more likely to say that religion is not personally important to them compared to the general population. Not surprisingly, therapists with lower levels of personal religious or spiritual involvement are less comfortable assessing and addressing these issues in treatment and have less favorable attitudes toward religion.34 The challenge then is that although the majority of us believe that religion can be helpful to our clients,35 many of us do not feel

why integrate religion into therapy? | 13

comfortable engaging in these issues because of unfamiliarity with religion.36 Lacking personal involvement in religion does not mean we are doomed to a feeling of discomfort or providing inferior treatment for our religious clients. The survey among CBT therapists discussed above revealed that when practitioners receive training regarding religious and spiritual issues in psychotherapy, the level of their own personal religiousness doesn’t matter. Even those with low personal religious beliefs report favorable attitudes toward religion and mental health treatment.37 In short, training matters when it comes to our attitude toward integrating religion into treatment and our comfort level doing so.

What If My Client Wants to Talk about Religion and I Don’t Believe in God? That’s okay. Remember, clients talk about a lot of things we don’t agree with, and religion is no different. Like everything else, the content of the session should be about their worldview, not ours, and how it impacts their mental and emotional functioning. One study even showed that Christian clients who received religious therapy from nonreligious therapists did better than when they received such therapy from religious therapists.38 The reason is not clear, but the finding is interesting nonetheless. One group of researchers at Iowa State University wanted to know how important it is for clients and therapists to share a religious belief system. The research team investigated what factors led to the greatest degree of clinical change and closeness between Christian clients and their therapists. Two hundred and twenty clients and fifty-­one therapists at Christian and secular counseling centers were surveyed.39 Interestingly, it wasn’t the similarity of religious commitment between clients and their therapists that mattered. Rather, when therapists used religious interventions that matched their clients’ level of religious commitment, Christian clients rated their change in symptoms and closeness to their therapists most highly. In other words, being of the same religious persuasion wasn’t

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necessary or important, rather it was administering a religious therapy for highly religious clients that enhanced the therapeutic relationship and led to better treatment outcomes. This is good news for therapists of all religious and nonreligious identities. When therapists are perceived as accepting and supportive of their clients’ religious faith and integrate it into therapy, they seem to facilitate greater client engagement, which increases the likelihood of successful treatment. Also remember what Christian CBT is not. It’s not about theology or biblical exegesis (a critical examination or interpretation of scripture). It’s not about preaching or converting. We don’t need to go to seminary to integrate our clients’ religious beliefs and practices into therapy. Indeed, being a practicing Christian does not qualify a therapist as being competent in CCBT. Rather, to develop competency, we need training and practice with real-­world clinical tools that will help us harness our clients’ religious resources, tools such as those described in this book. Finally, and perhaps most importantly, our clients are the experts on their religious beliefs. The more we ask, the more we’ll learn.

Christian CBT: A Therapeutic Approach for Treating Depression in Christian Clients Before we discuss what Christian CBT is, let’s briefly review the conventional CBT model. The more training in and experience you have using CBT, the easier and more skillful you will be in using Christian CBT (for training in CBT, see appendix B). The essence of CBT is that our thoughts, feelings, and behaviors are all interconnected. Change in mood and functioning rests on these bidirectional relationships: We can change how we are feeling by changing what we are thinking or how we are behaving. In CBT, clients are taught how to identify and evaluate their automatic thoughts and core beliefs. If they are experiencing depression or hopelessness, it is likely because some of the beliefs they hold are not helpful or

why integrate religion into therapy? | 15

accurate, and some of the behaviors they are engaging in (or not engaging in) hinder a sense of pleasure or mastery. CBT therapists invite clients to consider alternative ways of thinking and behaving with the goal of reducing feelings of depression. Christian CBT is based on the same principles as conventional CBT. Both are structured and directive; emphasize a collaborative partnership between the therapist and client; set specific session agendas and treatment goals; use Socratic questioning; identify, challenge, and seek to change unhelpful beliefs; modify behavioral patterns; and solicit client feedback.40 CCBT differs from conventional CBT in that it intentionally and explicitly uses the client’s own Christian beliefs, practices, and resources as the foundation for the application of CBT. In other words, therapists help clients harness their spiritual resources and Christian worldview to induce changes in what they think and how they behave in order to reduce depressive symptoms. In chapter 3 I go into greater detail about the CCBT model and the rationale for this therapeutic approach.

Overview of This Book By now I hope I have built the case that integrating religion into psychotherapy is more than inquiring about our clients’ religious affiliation or the importance of their faith. Integrating religion into psychotherapy means actively engaging and utilizing our clients’ faith to achieve psychological gains. This book is designed as a practical guide to help you do this for your Christian clients using seven specific religiously integrated CBT tools for the treatment of depression. I have structured this book so that each chapter and tool builds on one another. That being said, you don’t have to start with the first tool and work your way to the seventh. You may want to dip in and out of the tools, depending on the content of your sessions and the needs of your client. I do, however, recommend reading the second and third chapters before moving on to the chapters describing the tools. Chapters 2 and 3 give you a better context for the tools and understanding of when CCBT is most appropriate.

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Chapter 2 is designed to equip you with guidelines and assessment tools to determine whether CCBT is appropriate for your client. In chapter 3 I provide a more thorough description of CCBT. I also offer suggestions for how you can introduce this type of treatment to your clients, most of whom likely won’t know that such a treatment option is available to them. The next seven chapters describe the seven specific CCBT tools. Each chapter follows the same basic format. Every chapter begins with a clinical case describing a Christian client who is experiencing depression and a brief discussion on how the CCBT approach, and the specific CCBT tool to be highlighted in the chapter, could enhance treatment for this client over and above a conventional CBT approach. (All clients’ names and identifying clinical information have been changed in each chapter to protect the client’s confidentiality. Most cases are an amalgamation of a number of clinical presentations.) Next, the scientific support for the CCBT tool is reviewed, as well as the theoretical reasons researchers believe the tool helps to reduce depression. We learn how knowledge of the Christian religion provides a broadened perspective for treatment. Specific scriptural teachings and passages related to the tool are provided. Detailed instructions are provided on how to use the CCBT tool in a therapy session with skill-­building activities your clients can complete both in and between sessions. To enhance the practical application of the material, I offer sample dialogue you can use when introducing and explaining the tool to your clients. Finally, the chapter ends by returning to the case introduced at the beginning of the chapter to demonstrate a CCBT practitioner using the CCBT tool described. The seven CCBT tools described in this book that clients can use to combat depression are as follows: Tool 1. Renewing Your Mind: Planting Truth. Clients begin by learning how to fill their minds with positive and life-­giving truths through mind-­renewing activities, such as scripture memorization and contemplative prayer.

why integrate religion into therapy? | 17

Tool 2. Changing Your Mind: Metanoia. This modified classic CBT tool equips clients to take all thoughts captive by learning theological refutations for common cognitive distortions, and challenging and replacing negative and unhelpful thinking with the truth. Tool 3. Finding God and the Blessing in Suffering: Redemptive Reframing. After acknowledging and exploring spiritual struggles and sacred losses, this tool helps clients to reframe their suffering by taking a larger, faith-­filled perspective of their problems and actively searching for God at work in their lives. Tool 4. Reaching Out and Connecting. This behavioral tool combats social isolation and a lack of purposeful activity by encouraging clients to be involved in a religious community and exploring ways of doing so. Tool 5. Letting Go and Letting God: Acceptance and Forgiveness. After clients explore their hurts and resentments, as well as the distressing issues in their lives that are beyond their control, they can use forgiveness and active surrender to find inner freedom and healing. Tool 6. Saying Thanks: Gratitude. This tool helps clients cultivate gratitude, an attitude and emotional state incongruent with depression, by noticing the blessings they have been given and expressing their gratitude to God and others. Tool 7. Giving Back: Service. With this behavioral tool, clients shift their focus off of themselves and their problems by extending love and generosity to others through acts of service.

Key Principles ▶▶ Remember, on average, three out of four of your clients con-

sider themselves Christian. ▶▶ The majority of clients want to discuss religious and spiritual

issues with their therapist. ▶▶ CCBT is an effective treatment for depression.

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▶▶ You don’t have to be religious yourself to use CCBT. ▶▶ Together, mental health professionals and clergy make a

powerful healing team. Before we learn how to integrate these seven tools into therapy, we need to consider which clients are most appropriate for CCBT and how we can best make this determination.

Chap t er 2

Assessment Avoiding Assumptions

M

uch of the research on integrating religion into psychotherapy reports that Christian clients want their faith to be acknowledged and incorporated into treatment. That said, we can’t assume that just because a client identifies as Christian, she wants her Christian faith to be part of her therapy. Our research team at Duke University Medical Center ran into this issue when we first began recruiting for our religiously integrated CBT intervention study. We advertised the study as an opportunity for people who were depressed and had a medical illness to participate in research evaluating a type of psychotherapy that would integrate their spiritual and religious beliefs. Potential participants were told that they might receive conventional therapy (CBT) or a religiously integrated therapy that drew upon their religious and spiritual beliefs and practices. To participate, among other criteria, individuals needed to agree that religion or spirituality was at least somewhat important to them. This inclusion criterion was used because if religion or spirituality wasn’t important, it wouldn’t make sense to receive a treatment that included religion. Individuals also indicated their religious affiliation on the questionnaire, as we had developed a manual for Christian, Jewish, Muslim, Hindu, and Buddhist CBT. When a participant was randomized to the religiously integrated therapy and she had indicated she was “Christian” and that “religion

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or spirituality was at least somewhat important” to her, she would be assigned to the Christian version of CBT. A therapist would then contact the participant and begin treatment, which was offered over the telephone, using the Christian CBT manual. What we didn’t expect was having several participants drop out after the first session stating that the therapist talked about Christianity and quoted from the Bible. We were puzzled to say the least! We reached out to these participants and learned that although they considered themselves Christian, they identified as spiritual, not religious, and were not actively engaging in the Christian faith. It was an “aha” moment for us. We realized it was misleading to recruit people without clearly stating that they might receive an explicitly religious psychotherapy based on the religious affiliation they stated on the questionnaire. Once we changed our recruitment criteria to must be “at least somewhat religious” (no longer including the word “spiritual”) and “actively practicing your faith tradition,” we didn’t have any further issues in this area. The individuals who qualified for the study were the ones who wanted to have their religious faith integrated into treatment. I share this story to say that just because we know our client considers herself a Christian, and maybe even that spirituality or religion is at least somewhat important to her, it doesn’t mean that she wants a religiously integrated therapy. We need to have an open conversation with our client about what options are available to her, whether she identifies as religious or spiritual and what this means to her, and whether she would like her religious beliefs and practices to be part of her treatment. A second assumption to avoid is that if we know our client is a Christian, then we know what she believes. This point is especially critical for therapists who are themselves Christian and may feel an immediate bond with a client with whom the faith is shared. Yet sharing the same faith tradition does not mean sharing the same faith beliefs or practices. Christianity has countless denominations. Even knowing a person’s denomination does not mean knowing what that person believes, as beliefs and practices vary within

assessment | 21

denominations. I’ll go one step further. Even if you attend the same church as your client, you can’t assume you hold the same beliefs or practice your faith in the same way. Our clients are always the experts in what they believe and how they practice their faith tradition. Our job is to learn about our clients’ specific religious beliefs, practices, values, commitment, interpretation of scripture, and the degree to which they want their faith integrated into therapy, if at all.

Taking a Religious/Spiritual History To avoid these types of misunderstandings, we need to take a careful and thorough assessment of our clients’ religious and spiritual history. As Dr. Kenneth Pargament, one of the foremost experts in spiritually integrated therapy, has suggested, this history should include the following: ▶▶ How clients identify themselves (e.g., religious, spiritual, both, neither) and what this means to them ▶▶ Current and past religious beliefs and practices ▶▶ Changes in religious beliefs and practices ▶▶ Notable religious events ▶▶ The importance and salience of religion in their daily life ▶▶ Religious struggles and disappointments ▶▶ If and how they want their religious faith integrated into treatment1 This type of assessment provides us with a broad overview of our clients’ religious identity, worldview, and practices. It can also offer a springboard for a discussion on how our clients’ religious beliefs and practices might be a positive resource in psychotherapy. Later in this chapter, we also discuss what to do when it appears that our clients’ religious beliefs are making their depression worse. Below are suggestions for the types of questions we can ask to learn about our clients’ religious experiences and worldview.2 The questions are guidelines and are not meant to be used as a script. Use your clinical judgment for what questions to ask and in what

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order. Most important is the attitude in which we ask the questions and receive the answers. We may not agree with the responses we receive, but our clients need to feel that they and their beliefs systems are accepted and will be respected. As a culture, we are told that religion, politics, and sex are highly controversial subjects that usually should be avoided in conversation. This “rule” or assumption can show up in therapy, and as such, our clients may need “permission” from us to discuss their religious beliefs. Moreover, for some, talking about religion is even more delicate and private than talking about sex. As with all sensitive topics, we need to approach the subject of religion with genuine care, openness, and acceptance. The following are some suggested questions for taking a religious/spiritual history: 1. Do you consider yourself a spiritual or religious person? If religious, what religion do you follow? Are you affiliated with a specific denomination? If spiritual, what does this mean for you? 2. What role, would you say, spirituality or religion (or Christianity) plays in your life? 3. In what ways has this role changed over the course of your life? 4. Do you attend religious services or other religious activities? How frequently? 5. Do you pray? How often? What about meditating or other spiritual practices? 6. Do you enjoy reading religious or spiritual literature, such as the Bible? 7. What does the Bible mean to you? 8. Would you say you have a relationship with God? How would you describe this relationship? How has this changed over the course of your life?

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9. What sorts of struggles or disappointments do you have related to your faith, if any? 10. What effect, if any, does your depression [or whatever issue brings you into treatment] have on your spirituality or practice of your faith? 11. Is there anything else you would like me to know about your religion and its role in your life? 12. Would you like to incorporate your religious beliefs and practices into treatment? If so, how? [This question is a nice segue to explaining CCBT as an option for treatment.]

By taking the time to gather this information, we garner a better understanding of our clients’ specific faith tradition, beliefs, language, rituals, and sacred symbols. We can also learn if and how their depression may be hindering their ability to connect with their faith and participate in religious practices. CCBT is client-­centered, meaning that we are integrating our clients’ beliefs, practices, language, and resources, not those of Christianity in general (if there is such a thing), and not our own or anyone else’s understanding of Christianity. Client-­centered therapy also means beginning where our clients are right now. We use the religious resources they already have and proceed as they feel comfortable. We can use our clinical judgment and open dialogue to determine when and how to introduce more explicitly religious material, if our clients are interested. As we learned in our research study at Duke, not everyone who identifies as a Christian wants scripture or Christian beliefs and practices as part of their treatment. Taking this assessment also helps us determine if our clients’ religious orientation is having a positive or negative impact on their well-­being.3 As mental health providers, our goal is to improve each client’s well-­being by providing the best treatment possible. We won’t always agree with what our clients believe, even if we are also practicing Christianity, but we should avoid arguing with our clients

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about religious matters. Instead, we must take an open and curious stance and explore with them the impact their beliefs may be having on their emotional well-­being. Later in this chapter, I provide some guidance on what we should do when we run into a theological issue that is at odds with effective treatment. Despite the large amount of information gleaned from the religious history, we need to continue to learn about each client’s ­religious beliefs and practices throughout treatment. As with any other domain in therapy, we should never think we’ve got it all figured out. The way in which people understand and practice their religion is a complex and dynamic process—one that deserves our ongoing attention and respect.

Formal Assessment of Religious Involvement A number of empirically validated, standardized questionnaires are available for assessing our clients’ religious involvement in nuanced ways. For example, some measures assess spiritual and religious well-­being, daily spiritual experiences, intrinsic religiosity, conservative beliefs, and how people rely on religion to cope with challenges in life. Most of these measures are available free of charge, and many have been compiled into a book titled Measures of Religiosity.4 Hood, Hill, and Spilka also provide a list of religiousness and spirituality measures organized into twelve categories in their book The Psychology of Religion: An Empirical Approach.5 In appendix B, I provide a list of some spirituality and religiousness measures that are frequently used in research and that I think are useful in a clinical context.

Assessing Depression My assumption is that if you are planning on using CCBT to treat depression, then you are already proficient in assessing and diagnosing depression and are licensed to do so. As such, I only comment briefly on assessing depression when using CCBT. First, as

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with all empirical treatments for depression, it is good clinical practice to monitor the presence and severity of symptoms of depression throughout treatment to track progress or lack of it. Well-­known measures include the Beck Depression Inventory (BDI),6 the Hospital Depression and Anxiety Scale (HADS),7 and the Center for Epidemiological Studies–Depression (CES-­D).8 You can also use a very brief numerical mood rating scale at the beginning of each session: “Using a scale ranging from 0 to 10, where 0 is the worst that you’ve ever felt in your life and 10 is the best you’ve ever felt, what was your mood like on average this week?” Second, when working with Christian clients, using spiritual or biblical language when discussing the symptoms and impact of depression can be helpful. For instance, you might refer to their experience of depression as a “dark night of the soul” or as having a “downcast soul” or “broken spirit.” Some researchers have astutely noted that using such language provides clients with a “spiritual metric” with which to measure progress9 that may be more meaningful and congruent with their worldview. By helping clients to conceptualize their experience from both a spiritual and psychological perspective, you may also increase the credibility and acceptability of mental health treatment and their comfort level in working with you. In addition, using both perspectives emphasizes the possibility of experiencing both psychological symptom change (i.e., reduction in depressive symptoms) and spiritual growth (e.g., increased gratitude, altruism, and purpose in life), which research has shown occurs with religiously integrated therapy.10

Obtaining Informed Consent As other experts in the field of religiously and spiritually integrated psychotherapy have suggested, obtaining either written or verbal informed consent before engaging in CCBT and documenting such consent is essential.11 Informed consent means that the client understands the nature of the treatment, its potential risks and benefits, and possible alternative treatments. Clients need to be competent

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to give consent and do so voluntarily. Reasons that this is a prudent idea before beginning CCBT are as follows. First, obtaining informed consent is good clinical practice in general. It affirms the values of self-­determination, autonomy, and right to excellent clinical care.12 In addition, many licensure boards require obtaining informed consent from our clients before beginning any type of therapy. For example, the American Psychological Association’s Ethics Code Standard 10.01 states that psychologists obtain informed consent when providing therapy.13 Second, obtaining informed consent ensures that we have fully explained what CCBT is and what participation in this type of therapy entails. Our clients thus have the information they need to decide for themselves whether they want this type of treatment. It helps to ensure clients that they do not feel pressured or coerced into participating in any type of therapy they don’t want. Third, obtaining informed consent helps us stay within our scope of practice by outlining where the boundaries lie and when consulting with or referring to clergy would be more appropriate. This also sets up the understanding with our clients early on that clergy can play an important and valuable role in their treatment. This interdisciplinary approach can help some clients feel more comfortable seeking therapy in a secular context. Finally, as fitting with the principles of CBT, informed consent sets up a partnership between the therapist and client. Such collaboration increases the likelihood of positive clinical outcomes.

Self-­R eflection In addition to assessing our clients—for their interest in participating in CCBT, their religious history, and symptoms of depression—I recommend to all practitioners who want to use CCBT that they engage in their own religious/spiritual self-­reflection. You can ask yourself many of the same questions you will ask your clients. Doing so allows you to identify your own beliefs, biases, questions, and opinions. We will never be value-­free, and this is not the point of

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= Key Components of Informed Consent Experts in the field of spiritually integrated therapy suggest that a discussion designed to obtain informed consent should include the following components: ▶▶ A discussion of the differences between psychology and

religion and between psychotherapy and spiritual care. ▶▶ An outline of what is within a psychologist’s realm of

expertise and practice. ▶▶ A detailed explanation of the spiritually integrated treat-

ment (e.g., CCBT). ▶▶ A discussion of the potential benefits (e.g., reduction in

depressive symptoms) and risks (e.g., clients’ spiritual beliefs may change as a result of therapy). ▶▶ Alternative treatments available. ▶▶ How collaboration and consultation with their pastor

or clergy may be helpful. ▶▶ What constitutes a multiple relationship. ▶▶ What can be legitimately billed as psychotherapy.

self-­reflection. Rather, our goal is to be as self-­aware as possible so that we can monitor our own reactions during therapy and reduce our projections or unconscious defenses. For example, let’s imagine that you appreciate the morals and values espoused by Christianity but do not believe that Christianity

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is the only way to God or ultimate truth. You see the Bible as an allegory and respect it as one of the great literary works. You’ve had some intense debates in the past with your parents, whom you consider fundamentalist and overly concerned with your salvation. You think their literal belief in the Bible is naïve and at odds with science. For the last few years, you have avoided religious topics at family gatherings. Now let’s imagine you have a client who believes that Christianity is the only true religion, Jesus is the only way to heaven, and takes the Bible as literal truth. Your beliefs and experiences will be activated when working with this client. A conscious activation is desirable because it can be monitored and worked around. An unconscious activation can result in therapy-­disruptive behaviors, such as redirecting the conversation when issues related to the client’s religious worldview surface, purposefully not asking about the client’s religious beliefs and practices, feeling defensive, or even being confrontational. Recognizing that you have had strong reactions to these sorts of beliefs in the past alerts you to the fact that you may experience some of these reactions in the context of therapy. With this awareness, you can be intentional about seeking to understand your client’s Christian worldview by asking clarifying, open-­ended questions about how her belief system was formed, the meaning it has for her, and how it affects her current symptoms and recovery. This type of curious questioning will help you in the quest to understand and integrate her religious beliefs and simultaneously help keep you from consciously or unconsciously trying to change what she believes. The same potential for bias holds true for therapists who practice Christianity. We cannot assume that our clients believe the same things as us or practice their Christian faith in the same way. In fact, we should assume they do not. Furthermore, our goal is not to guide our clients toward the particular teachings we believe or the lifestyle we practice. Our goal is to help our clients harness their own beliefs and ways of practicing Christianity as a resource for overcoming depression.

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Whether we resonate more with the first description above or the second, it can be useful to remind ourselves that our clients’ worldviews are not a challenge or threat to our own worldview. Seeking out supervision or consulting with a colleague about the feelings and reactions we are experiencing is also a good way to remain objective and client-­focused.

When Religious Beliefs Are Part of the Problem At times, our clients’ religious beliefs can be the cause or maintaining factor of their depression. Some individuals hold religiously based beliefs and engage in religiously based behaviors that can be distressing and even damaging to themselves and others. On the extreme end, religion has been used to justify abuse, slavery, terrorism, and refusal of lifesaving medical intervention. In these cases, for the protection of our client or others, confidentiality needs to be broken so that the appropriate authorities can be notified. Other negative religiously based beliefs and behaviors may go undetected without careful assessment and can result in an exacerbation of depressive symptoms. For example, religiously based beliefs may inspire excessive or unwarranted guilt (e.g., a woman believes that God hates divorce based on a scripture passage, and so remains in a marriage that is harming herself and her children), shame (e.g., as a result of “sinful behavior” the person feels unable to change), prejudice (e.g., a person believes his religion is superior and expresses this to others), despair and hopelessness (e.g., a man thinks that he did not have enough faith to be healed of an illness), and conflict (e.g., one parent thinks spanking children is mandated in the Bible and the other believes this is morally wrong). It is not difficult to see how these types of religiously justified beliefs and practices might result in emotional distress, including a worsening of depressive symptoms, relationship problems, and health-­damaging behaviors. Nor is it difficult to see why it is important for mental health professionals to be aware of such beliefs and

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practices. However, as a therapist it can be tricky to know what to do once these potentially damaging religious beliefs and practices are identified. We must demonstrate respect for our clients at all times, which includes respect for differing and diverse religious worldviews, yet we must also promote health and well-­being and actively intervene when certain beliefs and behaviors put our client or others at risk of harm. As others have suggested, this is where collaboration with clergy is particularly important and helpful.14 Working with the client’s clergy member (or a clergy member of the same faith or denomination, if the client doesn’t belong to a religious community) can help illuminate the accuracy of religious interpretations. Before contacting the client’s clergy member, we first need to obtain a signed written release to do so. If we are unfamiliar with certain religious interpretations, beliefs, or practices that are relevant to treatment and our client does not give us consent to speak with her clergy member, we can consult another clergy member or expert in religion providing that we do not reveal any identifying information about our client. Confidentiality must be upheld in this case. Clergy can advise therapists on alternative ways of thinking and behaving that are in accordance with the theology of the client’s religious tradition. With the clergy’s input, our client might not feel the same need to defend her faith to her therapist, who she may already believe is biased against religion. This approach may allow her to be more open to considering alternative viewpoints. For example, a client who is feeling condemned or incapable of being forgiven for a certain action may be more likely to receive theological teachings about grace and mercy from a pastor than from a therapist. Involving clergy also helps the therapist to avoid his own religious biases and the potential for presenting his own belief system as the correct one.15 In addition to consultation, we can also make a referral to a pastoral counselor or clergy member, which again requires that our clients sign a release form in order for us to share information with clergy.

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Finally, the CBT tools presented in this book can also help our clients assess whether their religious beliefs are accurate reflections of biblical teachings. If there is a discrepancy, clients can use these powerful tools to challenge depression-­maintaining beliefs and do so in accordance with their value system. We discuss spiritual struggles, such as anger toward God, in chapter 6. As we saw in chapter 1, mental health professionals and clergy consult with and make referrals to one another infrequently.16 Professionals in both fields have a history of being wary of the others’ intentions and expertise. However, it may be that, for clergy, knowing that religiously integrated psychotherapy is available, and for mental health professionals, knowing the helpful role clergy can play in treatment, will help to lessen the disconnect between these two healing professions.

Chap ter 3

Introducing the CCBT Treatment Model to Your Client

I

n this chapter we explore the CCBT treatment model in greater detail. First, we review research that demonstrates the powerful effect our thoughts have on our brain, body, and behavior. Next, we learn how CBT works and why it is an effective treatment for depression, which leads us to a discussion about the similarities and differences between conventional CBT and CCBT. We’ll touch on the basic competencies practitioners need in order to use CCBT, and we’ll finish with ways we can introduce CCBT to our clients.

The Effect of Thinking on the Brain, Body, and Behavior Philosopher and poet Ralph Waldo Emerson once said, “We become what we think about all day long.” More than a century later, scientists and medical researchers have discovered that Emerson wasn’t just being poetic. The development and use of neuroimaging techniques has made it possible to study the brain in intricate detail. As a result, we now know that our thoughts aren’t abstract, amorphous things floating around in our heads. Instead, thoughts are made up of real, physical matter: molecules such as amino acids, neurotransmitters, hormones, peptides, and their receptors. Neuroscientists have also discovered that our brain is constantly changing—a phenomenon called neuroplasticity—and will do so for as long as we are alive. Mental activity, such as our thoughts, beliefs, and expectations, play an important role in changing the structure

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and function of our brains on a cellular, neural, and molecular level.1 For example, the more we have a particular thought, the stronger that neural network becomes; the less we have it, the weaker it becomes. The brain also changes whenever we learn something or develop a new skill. It’s not just our brains that change as a result of our thoughts. Our mental activity also influences what emotions we feel and how intensely we feel them. In fact, our entire body is affected by our mental activity through a cascade of biochemical events that influence complex information systems, such as our immune system and endocrine system. The messages these information systems deliver to the various parts of our body cause changes in our physiology and behavior.2 We literally do become what we think about.

How Does CBT Work? Neuroimaging has revealed that when people are depressed, their brains look and function differently compared to when they are not depressed. There are noticeable differences in the size and activation of various regions of the brain, including those necessary for functions such as cognition, emotion regulation, memory, and attention.3 Neuroplasticity is good news for all of us, but especially for those who experience depression. It means these brain abnormalities have the potential to change for the better. One of the reasons psychotherapy may be effective for treating depression is that it causes the brain to reorganize itself.4 Indeed, the abnormalities in the brains of people with depression have been shown to normalize after participating in CBT. In particular, a correction occurs in the dysfunctional connection between the cortical-­limbic system, which oversees the relationship between our thoughts and emotions.5 The cognitive strategies taught in CBT appear to activate the prefrontal cortex, which is involved in cognition, and diminish the activation of the limbic system, which is involved in emotional processing.6 These findings make sense theoretically because, in CBT, individuals learn how to alter their habitual negative thinking patterns

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to improve their emotional well-­being. Now we have the empirical evidence showing that when clients change their thinking style, they are changing which neural networks are used, thereby creating and strengthening some networks, while weakening others. Thus, the learning that occurs in CBT influences the strength of neural connections as well as the anatomy of the brain.7

The Conventional CBT Treatment Model CBT is a structured, time-­limited, and directive therapy that was developed as a treatment for depression by Aaron Beck in the 1960s.8 It is now the most empirically studied and validated treatment for depression.9 The CBT model states that our thoughts, feelings, physiology, and behaviors are all interconnected (see figure 3.1). By changing what we are thinking or what we are doing, we can change how we are feeling. In other words, this model rests on the premise that symptoms of depression reflect a deficit in cognitive and behavioral skills and functioning. As clients learn skills for changing their unhelpful thinking patterns and behaviors, they can experience a lessening of depressive symptoms. CBT Model

figure 3.1

What Do CBT and Christianity Have in Common? The CBT model and its foundational principles are not just congruent with Christianity; they are actually rooted in Christianity.

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Passages in the Bible, written thousands of years ago, speak of the relationship between our thoughts, feelings, and behaviors. Furthermore, the scriptures instruct believers to actively search their hearts (i.e., minds) for negative or sinful thoughts, and then to change or renew their minds for what they think is related to their emotional and spiritual well-­being. Thus, it could be said that, for Christians, the cognitive behavioral model is at least 2,000 years old.

= For as he thinketh in his heart, so is he. —Proverbs 23:7a KJV Tremble and do not sin; when you are on your beds, search your hearts and be silent. —Psalm 4:4 Search me, God, and know my heart; test me and know my anxious thoughts. —Psalm 139:23 Do not conform to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God’s will is—his good, pleasing, and perfect will. —Romans 12:2

CBT provides a theoretical framework congruent with Christianity, as well as practical tools that draw upon clients’ religious resources, for changing unhelpful or inaccurate beliefs and behaviors that may be causing or maintaining symptoms of depression. As such, CBT is a natural choice when working with Christian clients to modify cognitive and behavioral patterns. In fact, I think CBT is

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probably one of the most easily adaptable psychological treatments available when it comes to integrating our clients’ religious beliefs and practices.

Practitioner Competencies Needed for CCBT There are two key competencies that mental health practitioners, including pastoral counselors, need in order to effectively use CCBT for the treatment of depression. The first competency is professional training and proficiency—including state and national licensure— to diagnose and treat depression. The second competency needed for CCBT is basic training and clinical experience using conventional CBT. I will only briefly review the principles of CBT below to show how CCBT is both similar to and different from the conventional CBT treatment model. To learn more about CBT, and to receive training in this treatment modality, see the list of training resources in appendix B. Finally, familiarity with biblical texts and stories can certainly be helpful for therapists using CCBT, but it is not a prerequisite for using this treatment. For those who desire greater biblical knowledge, many resources are available that provide an introduction to the foundational teachings of Christianity and well-­known biblical texts (see appendix B for some suggestions).

The CCBT Treatment Model CCBT is unique because not only does it contain all the elements of conventional CBT, but it also adds the important contextual factors, worldview, values, and resources of Christianity that are not traditionally discussed or used in conventional CBT. In CCBT, clients learn how to use their religious teachings, rationales, values, and practices to help change dysfunctional beliefs and behaviors (see figure 3.2). This psycho-­spiritual approach promotes positive attitudes and behaviors, such as gratitude, generosity, forgiveness, acceptance, hope, and altruism. The goal of treatment is to create

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an optimistic, purpose-­driven, and meaningful outlook that is consistent with the client’s religious worldview and incongruent with depression. CCBT Model

figure 3.2

Introducing Your Clients to CCBT Most of our Christian clients do not know that a psychological treatment integrating their faith is available to them. As such, in order to offer CCBT as a possible treatment option to our clients, and to obtain informed consent, we need to provide a thorough explanation of the CCBT treatment model. Here is sample dialogue you might use to introduce CCBT to your Christian clients. Remember, as with all suggested dialogue in this book, this is not a script. You can modify the text with language that feels most natural to you and most helpful to your clients. Cognitive behavior therapy, or CBT for short, is an effective treatment for depression. CBT is based on the idea that our thoughts, feelings, physiology, and behaviors are all interconnected. This means that we can improve how we are feeling by changing what

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we are thinking and what we are doing. In CBT you will learn skills to change unhelpful thoughts and behaviors to foster a more positive mood. The theory of stress and coping states that it’s not an event that determines whether we feel stressed or upset; rather, it’s our interpretation of the event and whether we think we have the ability to cope with it. People with depression tend to see things more negatively than people without depression. This negative bias and their inaccurate beliefs help to maintain a depressed state. Let me illustrate with an example. Imagine that Lee and Amir apply for the same job. They are both equally qualified, but Lee tends to view himself and the world negatively and doesn’t think anyone would want to hire him. Amir, on the other hand, thinks he has as good a shot at the job as anyone else. How do you think Lee is feeling when he shows up for the interview? How do you think that is different from how Amir is feeling? What about differences in how they behave during the interview? Do you see how their beliefs set them up to feel differently, behave differently, and ultimately receive a different outcome? The interesting thing about CBT is that it can be easily modified to include your Christian beliefs and practices as important resources to help you combat depression. In other words, Christian CBT (or CCBT for short) helps you to harness your spiritual resources and Christian worldview to change what you think and how you behave in order to improve your mood. For example, you’ll learn how to develop more positive attitudes and behaviors, such as gratitude, generosity, forgiveness, acceptance, and hope. Ultimately, the goal of this treatment is to help you create an optimistic and hopeful outlook consistent with your religious worldview and incongruent with depression. The Bible says a lot about the reciprocal relationships between what we think, feel, and do. For example, in Proverbs it says, “As a person thinketh in his heart, so is he” (23:7KIV). The apostle Paul also spoke about the importance of what we think. He asserted that personal transformation and spiritual growth are a result of changing our minds. He taught the Christians in Rome, saying, “Do not con-

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form to the pattern of this world, but be transformed by the renewing of your mind” (Romans 12:2). CCBT will equip you with tools to renew your mind to reduce your depression.

When introducing clients to the CCBT tools outlined in this book, as well as the spiritual concepts associated with these tools, we need to show them how these concepts specifically relate to their own life experience and recovery from depression. A review of the literature on spiritually integrated therapies reveals that when therapists taught spiritual concepts and applied these concepts to their clients’ unique situations, the clients experienced better therapy outcomes than when therapists simply taught the spiritual concept without specific application.10

A Word about Home Practice Activities As with conventional CBT, an integral part of CCBT is the skill-­ building activities that clients complete during the interval between therapy sessions. These activities provide clients with the opportunity (and accountability) to practice the skills and tools they learned in therapy that week. Their experience completing or not completing these activities is then reviewed at the beginning of the next session. Clients can be encouraged to purchase a three-­ring binder in which to keep their CCBT worksheets and record their use of the CCBT tools. When treatment is complete, this binder becomes a valuable relapse prevention resource for clients, reminding them of the skills they learned and activities they can use to practice these skills. It is important to discuss early on with clients the role that home practice activities will play in treatment. No matter how helpful our sessions might be, we typically only see our clients for one hour each week. Our clients experience the majority of their learning and growing during the remaining 167 hours. We also need to keep in mind that some of the symptoms of depression are apathy and low energy. Therefore, if clients don’t complete an assignment, it’s

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important that we praise them for what they did do and brainstorm with them what they can do differently next time to be successful. Now that we have taken a thorough religious history, explained CCBT as a treatment approach for depression, and obtained informed (and hopefully enthusiastic) consent to implement CCBT, we’re ready to implement the specific CCBT tools in treatment.

Part Two Seven Practical CCBT Treatment Tools

Chap ter 4

Renewing Your Mind Planting Truth Whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think about such things. —Philippians 4:8

Meet Beth

B

eth is a twenty-­five-­year-­old Christian woman who has struggled with depression and poor self-­esteem for most of her life. She was born with a prominent facial disfigurement and has endured years of teasing and rejection because of her appearance. Beth spends much of her time at home alone. When she does have to leave the house, she tries to hide the disfigurement behind her long hair and colorful scarves. Church is the only place she feels comfortable enough to take off her scarf. She longs to be in a romantic relationship but doesn’t think anyone could ever desire her; it’s hard enough for her to develop friendships with other women. Beth sought out counseling after reading about how cognitive behavioral therapy can help people change negative beliefs about themselves and live happier lives. This excerpt is from her second session of CCBT. Beth: Every time I look in the mirror, I tell myself how ugly I am. Therapist: That must leave you feeling pretty down.

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Beth: It does. It’s gotten to the point that I avoid looking at my reflection. Therapist: You know, I don’t think we’re born thinking of ourselves as either good or bad or pretty or ugly. I think somewhere along the way we hear messages about ourselves, and the more we hear a message, the more we believe it. It doesn’t mean the message is true. Beth: My parents always told me that I was beautiful and that God made me special. I didn’t know I was ugly until I went to school and the other children laughed at me and told me I was scary looking and disgusting. Therapist: I’m so sorry you were told those awful things, Beth. Kids can be very cruel. I can see why you felt so sad and ashamed and how painful this experience is for you even now, years later. Beth: [shaking her head] Thanks, but the problem is that parents are supposed to say nice things to their children, and therapists are supposed to be supportive. I’d like to believe that the people who care about me are telling me the truth, but after all I’ve heard and the ways I’ve been treated, no offense, but I just don’t. Beth desperately wants to know and believe the truth about herself and her beauty. She has heard so many hurtful, negative messages that even the positive words she has received from people who love her are not enough to shift her opinion of herself. Beth needs a powerful tool to help her discern, and then believe, the truth about herself. Given Beth’s Christian beliefs, which she has spoken about in previous sessions, CCBT may be a more helpful approach than conventional CBT. CCBT will point Beth to an authority and resource Beth believes has greater credibility and claim on truth than herself, her family, or her therapist—that is, God and the Bible. In this chap-

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ter, we see how “Renewing Your Mind by Planting Truth” is a tool that reduces depression by changing the content and focus of our clients’ mental environments.

Scientific Support for Renewing Your Mind It only takes the brain a few weeks or months to produce visible physical changes as a result of learning a new skill.1 CBT is a skill-­ building treatment for depression that results in brain changes. Indeed, as we discussed in chapter 3, neuroimaging studies have shown that the skills people learn in CBT to control their thinking help to change the structure and function of the brain. These changes then directly impact their emotions, physiological state, and the behaviors in which they engage. CCBT may be effective for Christian clients because it taps into a strong organizing belief system that encourages optimistic and hopeful thinking, as well as a sense of meaning and purpose. This positive belief system may be a powerful way of rerouting and rewiring the neural circuitry of the brain. Research on meditation and prayer provides some evidence for this idea. Using an MRI scanner, researchers at Harvard peered inside the brains of individuals before and after they took an eight-­week meditation program called Mindfulness-­Based Stress Reduction (MBSR).2 They also took images of the brains of a group of nonmeditators over the same time period to provide a control condition. Holzel and colleagues found that the parts of the brain associated with learning, memory, self-­awareness, compassion, and introspection became denser (i.e., the gray matter in these brain areas increased) for the meditators, but not for the control group. The meditators also had a reduction in the density of the gray matter in the amygdala, a part of the brain involved in our emotional experience, including depression. A systematic review and meta-­analysis published in the Journal of the American Medical Association (JAMA), arguably the world’s

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most prestigious medical journal, reported that meditation can reduce depression with a similar degree of effectiveness as an antidepressant medication.3 This effect seems to be directly related to the structural and functional changes that occur in the brain from regular meditation practice. Something about spiritual meditation seems particularly helpful. After migraine headache sufferers practiced spiritual meditation for twenty to thirty minutes a day for one month, they reported a greater reduction in negative mood, anxiety, and migraine frequency and increased ability to tolerate pain compared to those who practiced nonspiritual meditation or muscle relaxation.4 In this study, participants in the spiritual meditation condition meditated on one of four spiritual phrases: God is joy, God is peace, God is good, or God is love. Another group of researchers found that Christians who meditated on a scripture passage for twenty minutes a day for two weeks reported less anxiety, anger, and muscle tension compared to those who used progressive muscle relaxation.5 Prayer is another meditative or contemplative state that alters the neural networks in our brain. Dr. Andrew Newberg, a neuroscientist at the University of Pennsylvania and author of the book How God Changes Your Brain, studies what happens in religious people’s brains when they pray or meditate. He has found that the brain undergoes very real changes when people enter this contemplative state. These neural changes may help to explain why some studies have shown that the more frequently people pray, the more likely they are to report greater well-­being, more meaning and purpose, and less stress.6 In sum, purposefully directing your mental attention through activities such as mindfulness meditation, spiritual passage meditation, and prayer can change your brain and improve your emotional well-­being.7 CCBT capitalizes on the brain’s ability to reshape itself by teaching clients how to intentionally engage in the mind renewing and quieting practices of passage memorization and contemplative prayer.

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Christianity and Renewing Your Mind with Truth To use the mind renewing tool most effectively with Christian clients, it is helpful to be familiar with four key teachings of Christianity. First, most denominations of Christianity teach that the triune being of God (i.e., God the Father, Jesus Christ the Son, and the Holy Spirit) is the embodiment of truth. For example, Jesus said, “I am the way and the truth and the life” (John 14:6a), and the Holy Spirit is referred to as “the Spirit of truth” (John 15:26). As such, for many adherents of Christianity, the words that God has spoken, which have been recorded in the Bible, are understood as truth, or at least as a set of valued principles (John 17:17; Ephesians 1:13). These teachings and principles often function as a fundamental organizing belief system for Christians’ worldview and value system. They also inform a way of thinking and behaving for Christians. A second key teaching is that many Christians believe in either a literal or figurative enemy of their souls called the devil or Satan. In scriptures, the devil is called the “Father of lies,” and is portrayed as a deceiving spiritual entity that tries to keep human beings from believing the truth (John 8:44). As such, clients may use language such as “evil thoughts” when talking about negative thoughts or speak about how the devil is trying hard to bring them down or make them believe something untrue. Third, Christians are advised to be vigilant about what they allow into their minds (often the mind is called the “heart” in scripture) because this is what governs their emotions, health, and behavior. As such, Christians are directed to actively seek and meditate upon the truth (Psalm 25:5). The Holy Spirit and scriptures are given to believers as ways to know the truth. Meditating on the truth is like planting positive seeds in the mind, which can produce a positive mood state. Finally, Christians are taught that the truth will renew their minds, set them free, and draw them closer to God and to His will for their lives.

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= My son, pay attention to what I say; turn your ear to my words. Do not let them out of your sight, keep them within your heart; for they are life to those who find them and health to one’s whole body. Above all else, guard your heart, for everything you do flows from it. —Proverbs 4:20–23

Religiously Integrated Skill-­Building Activities for Mind Renewing This section describes two activities that Christian clients can use to renew their minds by planting truth. Before introducing these activities, we should explain the concept of mind renewing and how this can be used as a tool to combat depression. A metaphor such as making deposits and withdrawals from a bank account or planting seeds in a garden can be an effective way to illustrate this concept. Here is one way you can introduce the mind renewal tool to your clients: When we are depressed, our minds are filled with negative and unhelpful thoughts. Dwelling on these thoughts keeps us in a downward spiral. To change our mood, we have to change what kinds of thoughts are occupying our minds. We need to be intentional about filling our minds with positive and uplifting words. You can think of your mind like a garden. If you plant a dandelion seed, you can’t expect to grow daisies! Given your Christian faith, you might consider using your favorite scriptures

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= Do not conform to the pattern of this world, but be transformed by the renewing of your mind. Then you will be able to test and approve what God’s will is—his good, pleasing and perfect will. —Romans 12:2 To the Jews who had believed him, Jesus said, “If you hold to my teaching, you are really my disciples. Then you will know the truth, and the truth will set you free.” —John 8:31–32

or encouraging spiritual teachings as a helpful way of shifting your thinking. These spiritual words and ideas can function as positive and truthful seeds that, once planted in your mind, can blossom into a more positive mood. The more of these seeds you plant, the better.

Scripture and Inspirational Passage Memorization One way clients can renew their minds with truth is by reading and memorizing scripture passages. Scripture memorization may not resonate for some clients. If this is the case, other spiritual and inspirational passages can be used for this exercise. Passage memorization can be introduced as follows: As we’ve discussed, what you are thinking about strongly influences your mood. We want to fill your mind with positive thoughts that line up with your value system. The more positive, values-­based words you have stored in your mind, the easier it

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will be to challenge and change your negative thinking, a skill we will learn in a few weeks. Some clients find that memorizing scripture is an effective way to deposit positive thoughts in their minds. Other clients prefer to commit to memory spiritual or inspirational passages from religious books and teachings. Is this something you’d like to try?

For clients who would like to try this activity, we can ask whether they have done this before, and if so, what that was like for them. Clients often report memorizing verses in Sunday school, but not since then. Discussing what made the activity easy or challenging provides us with a starting point for brainstorming strategies that will increase the likelihood of success. Strategies for memorization include the following: ▶▶ Write the passage on sticky notes and then post the notes on

the bathroom mirror, fridge, or any other place you are likely to see several times a day. ▶▶ Make it a game. Award yourself points for every time you

remember the verse correctly. When you reach a certain number of points, reward yourself with a prize of your choosing. ▶▶ Have family members or friends quiz you. ▶▶ Memorize the passage in small sections rather than all at

once.

This activity is not prescriptive, nor is it intended to lead to theological discussions or debates. Those types of exercises are the purview of clergy and outside the bounds of mental health practitioners’ training. Clients should be given the choice about what passage(s), if any, they would like to read and memorize. If your sessions have been focusing on a particular theme, you might suggest that they look for passages related to this theme. For instance, a client struggling with guilt might benefit from reading passages

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on forgiveness. Clients no longer need a physical Bible to read, as scriptures are easily searchable on the Internet and many apps are designed for this purpose. How to find passages to memorize: ▶▶ Do a keyword search using an online search engine or app

(e.g., BibleGateway.com) to find verses on a certain topic. ▶▶ Look in a Bible concordance or index for verses containing

specific words. ▶▶ Read some of the Psalms or Proverbs and look for verses that

speak to you. ▶▶ Buy a daily devotional book. ▶▶ Sign up online to receive a daily email containing a scripture

(e.g., VerseOfTheDay.com; TheDailyBibleVerse.org; Daily Bible Devotion app; Inspirational Bible Verses app). ▶▶ Look through inspirational books for meaningful quotes. ▶▶ Ask your pastor or other religious leader for recommendations.

Depending on how familiar you are with the Bible, you may also know some verses to suggest. In addition to the verses provided elsewhere in this chapter, here are several more well-­known passages:

= You will keep in perfect peace all who trust in you, all whose thoughts are fixed on you! —Isaiah 26:3 NLV For I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future,

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nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord. —Romans 8:38–39 The LORD is close to the brokenhearted and saves those who are crushed in spirit. The righteous person may have many troubles, but the LORD delivers him from them all. —Psalm 34:18–19 But he said to me, “My grace is sufficient for you, for my power is made perfect in weakness.” —2 Corinthians 12:9 I can do all this through him who gives me strength. —Philippians 4:13 Be still, and know that I am God. —Psalm 46:10

Contemplative Prayer: Meditating on God’s Word The second activity that clients can use to renew their minds with truth complements passage memorization. Contemplative prayer is a practice that involves meditating on scripture or inspirational passages. Engaging in this practice helps clients to think deeply about, remember, and apply the positive teachings they are reading. Contemplative prayer also ensures that there will be a certain amount of time each day devoted to positive and life-­giving thoughts, in contrast to depressive rumination.

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You can begin by asking your client if he has ever tried contemplative prayer or meditation. Your client’s answer will inform how you describe the practice and the plan you collaboratively set with your client to try this activity. Suggested dialogue for introducing contemplative prayer: One way to saturate your mind in positive, life-­giving messages is to meditate on scripture or inspirational passages. This practice is called contemplative prayer. Not only will it help you memorize the passages, it will also help you think more deeply about them and how they apply to your life. It’s a time that you spend alone with God, and many find it deepens their relationship with him.

Instructions for contemplative prayer: The instructions are fairly simple. You begin by identifying a verse or passage that is meaningful to you, perhaps a verse you are trying to memorize. You need to have the passage with you while you are engaging in this practice. You can use your Bible, tablet, or phone, or you can write the passage on a piece of paper. Then find a quiet place where you won’t be disturbed for a little while. Settle yourself into that quiet place and read the passage slowly. You might want to try reading it out loud. Then read it again, like you are savoring a delicious meal, letting the words slowly wash over your mind. As you do this, think about what the passage means. How does it speak to you? You might even ask God to show you what it means and how it applies to your life. Take a moment to be silent and just listen. You are cultivating a contemplative, prayerful state of mind. Then read the passage again, this time like a prayer said to God. What comes up for you this time? If you notice your mind wandering to other things, you haven’t done anything wrong. This is what our minds do. They are used to being busy and noisy. As with all forms of meditation, contemplative prayer takes practice. Rather than getting caught up in a train of thinking, just notice that your mind has wandered, and gently bring

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your attention back to the verse. Read it again slowly, pondering what it means and creating space within to listen. Some people like to have a journal with them to write down any thoughts or insights that come up during this time. When you are ready to finish, you may want to say a word of thanks to acknowledge the time you have just spent with God.

This will be a new activity for many clients. As with all types of meditation, it takes time and practice to settle the mind. It can be helpful to start with a short session—say, five minutes—and build on this. Ideally, this is a daily practice. Discuss with your client how long a session he would like to try, where he will engage in this practice, what time of the day is best for him, and what distractions he may need to minimize before beginning. The more specific a plan a client develops in session with us, the more likely he will complete the exercise at home.

Clinical Application Let’s return to Beth, whom we met at the beginning of the chapter, and see how a CCBT practitioner would have proceeded. Look for how the therapist uses passage memorization and contemplative prayer to help Beth renew her mind, as well as the impact this had on Beth’s core beliefs and mood. Therapist: It sounds like you’d really like to know and believe the truth about yourself, but it’s hard to know who to believe. Where do you usually go when you are seeking truth? Beth: You mean like ultimate truth? I guess that would be God. He only tells the truth. And I believe the Bible is true. Therapist: So you could trust God to tell you the truth about yourself? Beth: Well, yes, but it’s not like God is going to speak out of the heavens and proclaim to the world that I’m beautiful.

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Therapist: You’re probably right, but humor me for a moment. What if he did? Would you believe him? Beth: It wouldn’t feel true, but if he said it, and knowing he only tells the truth, then I’d have to work on changing my mind. Therapist: You’d have to renew your mind with that truth. That means you’d have to spend some time meditating on those words to get them to really sink in so you could believe them. Beth: Yes, I’d have to let my brain marinate in them. [laughs] Therapist: I have an idea. What if you went on a hunt for the truth? You said you believe the Bible is true. What if you did a search in the Bible for everything God says about beauty? Beth: That’s an interesting idea. I’m not sure I’ll find much, but it’s worth trying. I have a Bible app on my phone. I could search for the word “beauty” and see what comes up. Therapist: Perfect. Then if you find a passage that speaks to you, there are a couple of things that will help you “marinate” in it, as you put it. One is to memorize the passage so that you can refer to it often, especially when other negative thoughts come up. Another is to engage in contemplative prayer. Beth: Is that like meditating? Therapist: Yes, it’s very similar to meditating. Instead of focusing on the breath or counting, you read and reread the passage quietly, thinking about what it means to you, listening for what God might have to say to you about it. [Therapist explains more about contemplative prayer and they set a plan for Beth to try this practice daily over the next week.] The following week, the therapist asks Beth about her home practice assignments. Beth: To be honest, I wasn’t expecting to find much when we talked about this last week. I had no idea how much God has

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to say about beauty, especially women’s beauty. I found a passage in First Peter that says a woman’s beauty isn’t her clothes or hair or external appearance. It says a woman’s beauty is her inner self, her gentle and quiet spirit, and the Bible says this is of great worth to God. Then there was one in Song of Solomon that says, “All beautiful are you, My darling. There is no flaw in you.” When I read that I started to cry. Therapist: That sounds very powerful. Beth: It was. I used the verse about me not having any flaws for my contemplative prayer time. Each time I meditated on the verse it got a little easier to believe. Therapist: You were renewing your mind. Planting truthful thoughts. As you did, that truth was going deeper, taking root. Beth: It made me feel loved. My whole life I have felt ugly and defective. But if the one who created me says I’m beautiful, then I must be beautiful, even if I don’t feel that way. I still find myself hiding under my scarf when I go out, but I’m standing a little taller and I don’t feel as hopeless. If I can get to the place where I really see myself as beautiful, then maybe a man could see me that way, too. Therapist: I have no doubt about that. The more you can plant truth in your mind, the more your beliefs about yourself will change. And we know that when we have more positive, truthful thoughts, we feel better and we start behaving in different ways. Keep on marinating! For Beth, discovering that God—someone she believed was more objective and had more authority than her therapist or her family— said she was beautiful was critical for her acceptance of this beauty-­ affirming and mood-­changing message. For Christians, turning to scripture and other spiritual and inspirational texts can be a powerful means of planting positive messages in their minds. When these

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life-­giving messages take root, they can produce an emotional state incompatible with depression.

= Tool Summary Clients can renew their minds by planting truth using the following activities: ▶▶ Scripture and inspirational passage memorization ▶▶ Contemplative prayer: Meditating on God’s word

Chap t er 5

Changing Your Mind Metanoia We use our powerful God-­tools for smashing warped philosophies, tearing down barriers erected against the truth of God, fitting every loose thought and emotion and impulse into the structure of life shaped by Christ. —2 Corinthians 10:5 The Message

Meet Bill

B

ill is a forty-­five-­year-­old divorced Christian man who reports not feeling like his usual self since his divorce five years ago. After ten years of marriage, his wife asked for a divorce, and Bill continues to feel a crippling sense of regret, sadness, and guilt for his contributions to the failed marriage. He longs to start over with someone else, but he doesn’t feel worthy of a second chance at love. He believes that God is disappointed in him and he fears being rejected again. This is Bill’s fourth session of CCBT. Bill: If I had been a better husband, she never would have left me. Therapist: You’ve been struggling with this belief for a long time, haven’t you? Bill: I’ve thought about it every day for the last five years. It haunts me. I was a rising star at work, and everyone appreciated me there. The more I succeeded, the more Annie resented my career. That used to make me so angry. I see now that she

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acted that way because she was lonely. Eventually, she got tired of being alone all the time and left. Therapist: It’s not easy to face our contributions to a situation gone bad, like the dissolution of a marriage. Especially if we stop the reflection process there. Bill: The guilt is overwhelming. It’s not just that I got a divorce, it’s that I’m a Christian and I got a divorce. The Bible says God hates divorce. God gave me a wife and I blew it. Why should he give me another one? I’d probably just mess that one up, too. Bill is stuck in the story he has told himself about his divorce and what this means about him, and this story is maintaining his depression. Bill needs a tool that will help him address his negative beliefs about himself, God, and divorce and that will do so from a perspective congruent with his Christian faith and value system. Treating Bill’s depression from a CCBT approach will equip him with just such a tool. This chapter describes the CCBT tool “Metanoia,” a biblical term that means to repent or to change your mind about something.

Scientific Support for Changing Our Minds (Metanoia) The stories we tell ourselves matter. In fact, when it comes to our mood and well-­being, our stories about what happened, or what we think is going to happen, matter more than the event itself. Much research supports what Lazarus and Folkman named in 1984 the Stress and Coping Theory.1 These researchers asserted that it is not the events in our lives that determine how we feel, but rather our interpretation of the events as well as our ability to cope with them. For example, if we interpret something as negative, permanent, and out of our control, we will feel differently than if we interpret that same situation as not desired, but temporary and manageable. This theory applies to major life events, such as a house fire or divorce,

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and to smaller day-­to-­day events, like being late to a meeting with your boss. Research shows that people with depression make more negative and self-­blaming interpretations than do those without depression.2 This internal negative self-­talk often goes unnoticed and unchallenged and serves to maintain the depressive state. In contrast, an optimistic attitude and positive expectations elicit a positive emotional state and health-­promoting physiological changes in the body.3 Teaching clients how to identify and challenge their negative depression-­maintaining interpretations is the crux of CBT. The formation of positive beliefs and expectations may be one of the ways religious involvement in general and a religiously integrated approach to treatment reduces depression.4 For example, most Christians believe in an all-­powerful, ever-­present God who is loving, kind, gracious, and good. They believe God will help them during times of trouble, acting on their behalf to bring about a good plan for their lives. They also have the hope of heaven and an eternity spent with God when they die. A Christian belief system can be a powerful source of positive, hopeful, and optimistic expectations and interpretations that is incongruent with depression.5

Christianity and Metanoia Christianity has a lot to say about what and how we think. The apostle Paul taught the early church in Corinth that the mind is a battlefield and every thought is to be carefully examined to determine whether it is a friend or foe: “We demolish arguments and every pretension that sets itself up against the knowledge of God, and we take captive every thought to make it obedient to Christ” (2 Corinthians 10:5). In other words, some thoughts can be damaging, and as such, all thoughts are to be examined and challenged rather than passively accepted. In keeping with the battle imagery, when Paul describes the armor a Christian wears, the only offensive weapon given is the “sword of the Spirit, which is the word of God” (Ephesians 6:17). Another

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scripture describing the word of God as a sword is found in the book of Hebrews: “For the word of God is alive and active. Sharper than any double-­edged sword, it penetrates even to dividing soul and spirit, joints and marrow; it judges the thoughts and attitudes of the heart” (Hebrews 4:12). Thus, for Christians, the Bible can provide a judgment or a standard of truth against which thoughts are evaluated for their accuracy. If the thoughts are found to be inaccurate or unbiblical, scriptures instruct Christians to wage war against those thoughts by using the word of God as truth. In CCBT, therapists offer Christian clients the opportunity and skills to examine their thinking patterns against the teachings of Christianity and the Bible. In this process, the therapist does not function as a priest or pastor. It is not a top-­down, authoritative approach where we as therapists have the truth to give to our clients; all we have are simply our own interpretations of Christian teachings and scripture. Rather, in CCBT, we as therapists function as guides and partners in our clients’ pursuit of truth. We invite clients to explore beliefs that may be contributing to their depression. When these beliefs are identified, clients can evaluate whether they line up with the teachings of Christianity they have accepted. If the beliefs don’t line up, the client can use the teachings of the Bible and other sacred and inspirational texts and messages to provide alternative beliefs, ones that are not congruent with depression. Of note, scriptures themselves may be inaccurately interpreted or used in a way such that they contribute to a client’s depression.6 Therapists who encounter this situation are wise to seek counsel with those trained in theology and biblical analysis and interpretation. Others have compiled useful scriptures and biblical themes for therapists who desire to learn more about the scriptures and how these texts are generally understood among Christians.7

Religiously Integrated Metanoia Skill-­Building Activities The tool described in this chapter is the heart of CCBT for treating depression: Changing your mind (metanoia) using the ABCD(R)

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E approach. This is a modification of the classic CBT tool known as the ABCDE approach for cognitive restructuring developed by Albert Ellis.8 In CCBT, the ABCD(R)E tool equips clients to draw upon their religious resources to win the war in their minds. First, clients learn how to identify their depression-­causing or maintaining beliefs, most of which occur without conscious awareness. Then they learn how to challenge and replace these thoughts by drawing upon scripture and Christian teachings as a source of positive and life-­affirming beliefs. Metanoia or cognitive restructuring is a client-­centered rather than prescriptive process. This is why Socratic questioning and guided discovery are inherent to CBT and CCBT; clients, not therapists, are the ones who ultimately decide if and how to change their own beliefs. How to introduce the Changing Your Mind / Metanoia tool to clients: We have seen how some thoughts make us feel miserable, while others make us feel better. What matters more than what happens to us is the way we interpret what happens and whether we think we’re able to manage it. [Provide an example relevant to your client to illustrate this concept]. In Christianity, your mind is characterized as a battlefield, full of thoughts that may or may not be good for you. We aren’t supposed to be passive observers in this war, but when we’re depressed we don’t feel like doing much, let alone fighting in a war. However, this is a battle you need to engage in to defeat your depression, and I am going to give you some powerful tools to help you win that war. The apostle Paul taught the early church to fight the battle of the mind by taking “all thoughts captive to the obedience of Christ.” To do this, we first need to recognize when an enemy thought has entered your mind.

Identifying Distorted Thinking Styles When learning how to change depressive thinking, a good place to begin is with common distorted thinking styles. When clients

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have labels for their various thinking patterns, they are better able to identify what thoughts are contributing to their depressed mood. This is a standard part of CBT. What differentiates CCBT from conventional CBT are the theological reflections that provide a biblical perspective for why a particular thinking style is distorted. The theological reflections also serve as a model for clients on how to use their Christian beliefs and values to challenge negative thoughts. As this worksheet is lengthy, with a lot of information to digest, I have found it helpful to have clients read it on their own (see figure 5.1). Then I review it with them in the next session. During this review, we can ask our clients which thinking styles they find themselves using most frequently. It can be comforting to share that we all have our favorites and we all fall into these ways of thinking at times. Our goal is to equip clients to recognize these thinking patterns quickly so that they can challenge these types of thoughts and win the battle in their mind. We can also ask what they think of the theological reflections and whether they agree, from a Christian point of view, that these thinking styles are distorted. Some clients may be able to think of other stories or teachings from the Bible that help to refute a particular maladaptive way of thinking. These are ten common styles of distorted thinking that contribute to feeling depressed. For each, an example is provided illustrating why this way of thinking is problematic from a Christian perspective.

Figure 5.1. Ten Common Distorted Thinking Styles 1. All-­or-­Nothing Thinking You see things in black-­and-­white categories. For example, if your performance falls short of perfect, you see yourself as a total failure. This way of evaluating things is unrealistic because life is rarely completely one way or the other.

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Theological reflection: Jesus told his followers that they are to hate evil; yet he also said that they should love and pray for their enemies, rather than judge or condemn them for doing wrong. Extending grace to others seems to mean seeing the world in shades of gray, rather than in strict black-­and-­white terms. 2. Overgeneralization You see a single negative event as a never-­ending pattern of defeat. For example, if you are turned down for a job, you tell yourself no one will ever hire you. Theological reflection: In the Gospel of John, when Jesus was arrested, Peter denied ever knowing him. One might assume that Peter had failed as a friend and could never again consider himself worthy of friendship with Jesus. However, after the resurrection, Jesus engages with Peter in a loving manner and entrusts to him the sacred mission of sharing the gospel message with others. Peter openly proclaimed his love for Jesus for the rest of his life. One failure didn’t mean a lifetime of failure for him. 3. Mental Filter You pick out a single negative detail in a situation and focus exclusively on this. In doing so, you ignore or filter out any positive details or feedback. Theological reflection: Scripture gives clear instructions on what to focus our thoughts on: “Whatever is true, or lovely, or gracious . . . think on that. If there is any excellence, if there is anything worthy of praise . . . think about that” (Philippians 4:8). To do this, we need to acknowledge and reflect on the positive things we have been given and accomplished and the positive feedback we have received; we are not to ignore or filter these things out.

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4. Disqualifying the Positive You disqualify positive experiences by insisting they “don’t count” for some reason. In this way you can maintain a negative belief that is contradicted by your everyday experiences. You don’t just ignore positive experiences as with the Mental Filter; you intentionally devalue them. Theological reflection: When the Israelites experienced hardships in the wilderness on the way to the Promised Land, they decided that God had rescued them from slavery in Egypt only in order to kill them in the wilderness (Exodus 16:3). They disqualified God’s promises and the miracles he had done on their behalf to deliver them and to sustain them in the wilderness. As a result of disqualifying these positives, they made an inaccurate assessment of God’s character and his purpose for rescuing them from the Egyptians. 5. The Fortune-Telling Error You jump to conclusions by anticipating that things will turn out badly. You feel convinced that your predictions are an already established fact even though no one can predict the future. Theological reflection: Jesus told his followers not to be anxious about the future because he is in control and has promised to take care of them (Matthew 6:25–34). By worrying and imagining a negative future, not only do we not improve the situation, but we also act as if we do not trust God to keep his promises. 6. Catastrophizing You inappropriately exaggerate the importance of things, such as thinking that a mistake you made was the worst possible outcome. By distorting reality, things appear worse than they are. Theological reflection: After Judas betrayed Jesus, he felt so guilty that he saw no solution for his actions other than killing himself. Although his actions were certainly grievous, Jesus

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had a history of demonstrating grace and forgiveness. Indeed, restoration of humankind’s right relationship with God was the purpose of Jesus’ death and resurrection. Judas’s interpretation of his action was a distortion of reality, one that cost him his life. 7. Emotional Reasoning You assume that your negative emotions necessarily reflect the way things really are: “I feel it. Therefore, it must be true.” Our emotions are a reflection of our thoughts, beliefs, and physiology; they are not necessarily a reflection of the true state of affairs. Theological reflection: Individuals in the Bible are described as having times of dryness and darkness, times when they yearned for God, but did not feel his presence. However, not feeling God’s presence did not mean he was absent, because God says he will never leave or abandon us. Their feelings of being alone were not a true reflection of the situation. We are asked to put our faith in God’s promises, not in our feelings. 8. Should Statements You try to motivate yourself with shoulds and shouldn’ts, as if this is the only way you can get yourself to do something. When you don’t do something you think you should have done, you feel guilty. When you direct should statements toward others, you feel anger, frustration, and resentment. Theological reflection: One of the central themes of the New Testament is that Christ has accepted us, forgiven us, and given us a spirit of freedom. As such, there is no need to condemn ourselves if we do not perform the way we or others think we should have performed (Romans 8:31). If we make a mistake, the Bible says that we are to confess our sin to God and that He immediately forgives us and puts that sin as far away as the East is from the West. His love is a gift of grace, not a result of us earning or deserving it.

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9. Labeling This is an extreme form of overgeneralization. Instead of describing your error or behavior (e.g., I failed the exam), you attach a negative label to yourself (e.g., I’m a failure). When someone else’s behavior bothers you, you attach a negative label to that person (e.g., he is a jerk), rather than describing the behavior. Theological reflection: God loves us unconditionally and rejoices in us even when our behavior is not pleasing to him. For example, in the parable of the Prodigal Son (Luke 5:1–24), the father eagerly welcomes the son back home even though the son has squandered his inheritance and disgraced his family. This parable—a story meant to teach us about God’s relationship with humankind—demonstrates that the son’s identity and worth were not based on his behavior, but simply on being his father’s son. Likewise, our identity and worth are not based on what we do or don’t do, but simply on the fact that we are God’s children. 10. Personalization You see yourself as the cause of some negative external event for which you are not responsible. While we have some influence over people, what they do is ultimately their decision and responsibility, not ours. Theological reflection: God has control over the events that happen in the world. We, for the most part, do not. We should not presume to be God or try to fill his shoes, especially when negative events happen to us. There are many things we will not understand in this life and many things over which we have no control. In these situations, the scripture says we are to “be still, and know that I am God” (Psalm 46:10).

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* Note on theological reflections: Although the author has tried to choose examples that can be generally applied across various branches and denominations of Christianity, clients may have different theological beliefs than those represented here. It is important to review these examples with our clients to see if they are applicable within their religious framework. If they are not, we can ask our clients for examples that better fit with their belief system. In addition, therapists may not have prior knowledge of these passages and theological examples. In this case, we need to be up front with clients rather than being in the uncomfortable (and unethical) position of posturing ourselves as knowing more than we do. Regardless of a therapist’s familiarity or agreement with the theological reflections, we can present them as potential examples of how one might use scripture passages and teachings to help refute problematic thinking styles. We can and should also elicit other examples from our clients. Source: Adapted from Ciarrocchi, Schechter, et al., Religious Cognitive Behavioral Therapy; Propst, Ostrom, et al., “Comparative Efficacy.”

ABCD(R)E Method of Identifying and Challenging Thoughts The ABCD(R)E method is briefly outlined here in two stages and then demonstrated in the clinical application at the end of the chapter.

Stage 1: ABC The first stage of the ABCD(R)E method comprises steps A (Activating event), B (Beliefs), and C (Consequence: Feelings and behavior). With our guidance, clients write down their answers for each step. A sample thought monitor is included here for this purpose (see figure 5.2). It has been said that we have thirty thousand thoughts every day. We are aware of very few of these thoughts! The goal of the ABCD(R)E

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method is to help you notice your automatic thoughts and beliefs that contribute to feeling depressed. This week you’ll learn how to identify these thoughts using three steps: A, B, and C. Next week, I’ll show you how you can challenge and change your thoughts to feel better using the final three steps.

We begin by asking our clients for a recent situation in which they experienced a negative emotion. We then use their example as we walk them through steps A, B, and C. Of note, although the first step in the process is the activating event (step A), usually the first thing clients notice is that they are feeling a negative emotion. As such, it is helpful to tell clients that they can use the experience of a negative emotion (step C) as the indicator that they just had an automatic negative or unhelpful thought about a situation. This cues them into the need to stop what they are doing and use the ABCD(R)E approach. Walk your clients through steps A, B, and C using a recent situation and have them write down their responses for each step on the thought monitor. When clients are first learning this tool, writing down their responses makes the cognitive restructuring tool and concepts more concrete. Writing down their thoughts also makes the process seem more objective and malleable than when it is completed in their heads. The goal, however, is that with practice they will become so proficient with this tool that they will no longer need to use a thought monitor. Figure 5.2. ABCD(R)E Thought Monitor for Changing Your Mind: Metanoia Activating Event: Describe what was happening when the negative emotion(s) began. (Who? What? Where? When?) Beliefs: What negative beliefs or expectations automatically went through your mind when you were in that situation? (What is your interpretation of what happened?) Specify the unhelpful thought category that best describes the error in the belief.

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Consequence for Feelings and Behavior: What feelings resulted from these beliefs or expectations (e.g., sadness, guilt, anger)? Rate the intensity of each feeling using a scale of 1 to 10, where 10 is the most intense. .

What behavior did you engage in (or not engage in) as a result of these beliefs and feelings? (Did you behave in a way that is unhelpful or harmful to yourself or others?) To practice identifying their automatic negative thoughts, clients should complete an ABC thought monitor at least once a day until their next session. It is important that clients are proficient in the first stage of the ABCD(R)E method before moving on to the next stage, where they will learn how to change their minds.

Stage 2: D(R)E The second stage consists of the final three steps: D (Disputing the beliefs), R (Religious resources), and E (Effective new belief and consequences). We begin the session by reviewing our clients’ ABC thought monitors for completeness, ensuring comprehension of the key components of the first three steps. As we walk our clients through steps D, R, and E, they will write their responses down on the ABCD(R)E thought monitor. What makes CCBT unique is step R (situated between steps D and E) in which clients are instructed to use their religious beliefs, teachings, scripture, spiritual writings, and other religious resources to help challenge and change their negative beliefs or expectations. Here is one way to introduce the final three steps of the Metanoia tool: Now that you have learned how to identify your negative thoughts, I’m going to show you how to challenge and change those thoughts so that you can experience a more positive mood. As we discussed, there is a battle for truth going on in our minds. When we discover a thought that is not true or not helpful, we need to do something

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about it. We find in the New Testament a tool that will help us do this: Metanoia is an ancient Greek word that means “to repent or change your mind about something.” John the Baptist and Jesus referred to their ministries as calling people to metanoia, or to repentance. I’m going to show you how you can use your religious beliefs, practices, and values to assist you in the process of metanoia. The verses you have memorized will be helpful in this process.

Figure 5.2 (continued). ABCD(R)E Thought Monitor for Changing Your Mind: Metanoia Dispute the Beliefs: What evidence do you have that your beliefs or expectations are not accurate, true, or helpful? What evidence do you have that you could manage the situation (based on your talents, past experience, support persons, or resources)? Religious Resources: How can your view of God, your Christian worldview, the Bible, religious writings, and other sources of spiritual wisdom provide evidence that challenge your automatic negative beliefs? Effective New Belief and Consequence: What is a more accurate and helpful way of looking at the situation? Does this new belief change how you feel? Rate the intensity of each feeling again using a scale of 1 to 10, where 10 is the most intense. The heart of CCBT is to show clients how they can draw on their religious beliefs, teachings, values, and practices to challenge and change depression-­maintaining beliefs and behaviors. For example, a client who feels alone in the world (and who may indeed be socially isolated) may feel less lonely when considering scriptures that speak of Jesus never leaving or forsaking him and being close to the brokenhearted. Knowing that he is loved and never truly alone may give this client the courage to reach out to others, a behavior that would work toward lessening his depression. This type of consolation is unique to and based upon his Christian worldview, and may be a valuable resource he had not previously considered in this way.

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Scriptures encourage believers to think and act in ways that do not seem consistent with what happens in their lives. The apostle Paul was beaten, thrown in prison, shipwrecked, and starved, yet he told the early Christians that he rejoiced in the Lord always and had “learned to be content whatever the circumstances” (Philippians 4:11). He interpreted every event in his life, whether positive or challenging, as an opportunity to share the gospel, which he had made his life’s purpose. You can use examples like this to demonstrate to clients the CCBT model in action within the scriptures.

Clinical Application Let’s return to the case about Bill and see how the ABCD(R)E method for metanoia was used, along with scriptures about God’s unconditional love and forgiveness, to help Bill challenge his negative beliefs. Bill learned steps A, B, and C in his previous therapy session. In the excerpt below, he learns the last three steps: D, R, and E. Therapist: You’ve done an excellent job completing your thought log. Today I’d like to teach you the last three steps of the ABCD(R)E method. I’ll also show you how you can draw upon your religious beliefs and values to help shift your thinking and your mood. In step B, you identified several negative beliefs: “If I had been a better husband, she never would have left me. God is disappointed in me because I got divorced. I’ll always be alone.” How did these beliefs make you feel? Bill: Miserable, guilty, sad. I rated them all as 9 out of 10. Therapist: You were feeling pretty bad after having those thoughts. What were the behavioral consequences? Bill: I didn’t respond to any of the women on the online dating site, not even the one I was interested in getting to know. I skipped church again on Sunday. I just stayed home and watched TV all weekend. Therapist: Did any of those behaviors make you feel better?

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Bill: No, they made me feel even worse. Therapist: So, you can see how thinking those negative thoughts and engaging in those socially isolating behaviors left you feeling more depressed. It’s time to examine those thoughts more carefully and see if they are thoughts worth believing. We talked last week about the war going on in your mind and about metanoia, which means changing your mind or repenting. Steps D and R will help you with that. Step D stands for disputing your beliefs. Let’s fill in the next sections in the thought log, starting with the first belief. What evidence do you have that this is not true or not helpful? Bill: Well, I do think that if I had been more attentive to Annie and didn’t spend so much time at work she would have been happier. The problem was I didn’t know how unhappy she was. I knew she resented my job, but I had no idea she was thinking of leaving me. Therapist: Would you have behaved differently if you had known that? Bill: Yes, I really think I would have. Once she told me how she was feeling, I told her how wrong I had been and begged her to go to counseling with me. She refused, said she was done. Therapist: I’m sure that was very difficult, not being given a chance to address her concerns or to change. Bill: Yes, it felt very unfair. I was willing to change, and I did change after that, but in her eyes it was too late. Sometimes I think she just got tired of being married and wanted a different kind of life, a more exciting life. If I had been more attentive, more available, I don’t think she would have felt this way. Therapist: It sounds like you believe you deserved to be left. Bill: I do.

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Therapist: Let’s see if step R, your religious resources, can help you challenge the belief that you deserved to be left. How can your view of God, your Christian worldview, the Bible, or any other sources of spiritual wisdom provide evidence that challenge this belief? Bill: I believe God takes marriage very seriously. At the altar, we make a commitment before God to love our spouse for life. It doesn’t mean our spouse will always be easy to love! That’s why Jesus emphasized our need to give grace and forgiveness to one another and to receive those things ourselves because we’re all going to mess up. Therapist: Yes, we’re all going to mess up, even when we love someone very much. Based on these teachings, what can you say about the belief that you deserved to be left? Bill: If I had refused to change once she told me how she was really feeling, I can see how that would have been destructive. I wouldn’t have wanted either of us to be in a marriage that was destructive. But I repented to her and to God. What I needed was grace and forgiveness and a chance to be a better husband, not a divorce. I would have done that for her had the roles been reversed. Therapist: It sounds like she made a decision that did not line up with your value system. In the end, who is responsible for the divorce? Bill: When you put it like that, she is. Therapist: Given what you believe the Bible teaches about grace and forgiveness, what do you think God thinks of you now that you’re divorced? Bill: Well, He knows I didn’t want the divorce and I have repented of my actions, many times. [pause] You know, all this time I thought God was upset with me, but the truth is God

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forgave me even though my wife did not. It’s not God who needs to forgive me; I’m the one who hasn’t forgiven me. I have never thought about it like that before. Therapist: Those are good insights. Are you saying that God’s love and acceptance aren’t contingent upon your marital status? Bill: That’s right. His love isn’t based on my marital status or my failures. But I’ve sure been acting like it is. Therapist: How do these two new beliefs make you feel: My wife is responsible for the decision to divorce, and God’s love and acceptance for me are not based on my marital status or failures? Bill: Much better. I don’t feel that awful weight of guilt or regret. I’m still sad it worked out this way because it’s not what I wanted. At the same time, I see that I was being far too hard on myself and believing things that the Bible says aren’t true. You know, maybe if I found someone who believes the same things I do about marriage, it might actually work a second time. Bill began the session with some very negative beliefs that had helped to maintain his depressed mood for many years. Until he examined his thoughts in light of his religious resources, he was sure that what he believed was true. Once he thought about his Christian value system and what he believed Christ taught about grace and forgiveness, he was able to interpret his situation in a less self-­ condemning manner. His Christian worldview provided a powerful framework for challenging and changing his beliefs about deserving to be divorced and disappointing God, as well as his prediction of continual rejection. For Bill, using the tool of metanoia, along with evidence from his religious resources, reduced his feelings of misery and created hope for a better future.

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= Tool Summary Clients can change their minds (metanoia) by using the ABCD(R)E method: ▶▶ Identify depression-­ causing or maintaining beliefs

and distorted thinking styles using theological reflections. ▶▶ Challenge and replace these thoughts by drawing

upon scripture and Christian teachings as a source of positive and life-­affirming beliefs.

Chap ter 6

Finding God and the Blessing in Suffering Redemptive Reframing

Consider it pure joy, my brothers and sisters, whenever you face trials of many kinds, because you know that the testing of your faith produces perseverance. Let perseverance finish its work so that you may be mature and complete, not lacking anything. —James 1:2–4

Meet Maria

M

aria is a forty-­two-­year-­old Christian Hispanic woman who endured twelve years of domestic violence before escaping three years ago. It’s hard for her to trust people now, and as a result, she has only a few superficial friendships with coworkers. She is lonely and sad, and suffers from severe insomnia. Her faith remains very important to her, but she cannot come to terms with how a loving God could have let her endure such abuse. Maria: All those years I prayed for God to help me, to make him stop. He rescued the Israelites when they were beaten and enslaved by the Egyptians. He split the Red Sea for them and defeated armies on their behalf. Why didn’t God deliver me? Therapist: It’s so hard to make sense of it. Maria: His silence made me feel alone and unimportant. If I can’t trust God to be there for me, there’s no way I can trust anyone else.

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Therapist: I’m sure it does make trusting others challenging for you. God, the very one you thought would protect you no matter what, seemed absent when you needed him the most. Maria’s pain extends far beyond the physical abuse she endured for twelve years. She is in spiritual pain; her understanding of God and her value to him have been seriously challenged, and this pain is at the root of her depression. Her ability to trust others seems dependent upon her ability to trust that God never left her alone and has a redemptive purpose for her suffering. Maria needs a way of understanding her suffering that takes into account her Christian worldview. As she works to reconcile her experience of abuse with her faith, one of two things will occur: She will either change the beliefs she held about Christianity before experiencing domestic abuse to better fit with her life experience, or she will change her perception of her experience and God’s absence to fit better within her Christian belief system. Maria would likely benefit from the third CCBT tool called “Finding God and the Blessing in Suffering,” a tool that allows clients to explore their spiritual suffering and, if desired, engage in a redemptive reframing of this suffering. With this tool, clients use meaning making and benefit finding from a Christian perspective to help improve their mood and well-­being.

Scientific Support for Redemptive Reframing Very few of us would ever volunteer to experience loss, abuse, tragedy, or other such life-­shattering events. Yet when we look back on our lives, many of us would agree that some of our greatest personal and spiritual growth occurred during these unwanted times. Often we state that paradoxically we are stronger or somehow better for going through these painful experiences. Researchers call this phenomenon “posttraumatic growth.”1 People who experience posttraumatic growth report being more resilient the next time they encounter a difficult event, having a new life purpose, gaining wis-

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dom and a greater appreciation for life, and experiencing spiritual growth.2 One key factor for experiencing posttraumatic growth, or at least for regaining psychological stability, is the meaning we ascribe to painful events.3 Without finding a sense of meaning, we are more likely to experience ongoing emotional distress, spiritual crises, and poor health.4 In fact, meaning is a better healer of all wounds than is time.5 People who seek to find the silver lining or possible benefits from their painful experience are also more likely to report experiencing posttraumatic growth and better mental health.6 Religious individuals often rely on their faith to make sense of negative circumstances and to find comfort.7 Indeed, when people’s religious beliefs are supported and actively engaged, they tend to experience greater recovery and resilience following negative life events.8 One way to engage religious beliefs for healing is to write about a distressing experience using one’s religious worldview as a framework for meaning. Individuals who have done this have reported fewer symptoms of depression and posttraumatic stress disorder.9 Painful life events can also result in spiritual crises, a type of existential distress that can cause a deterioration or loss of one’s religious beliefs, religious community, and sense of religious identity.10 People who experience spiritual crises and unmet spiritual needs are more likely to also experience depression, anxiety, low quality of life, and poor physical health.11 One study also found these individuals are at greater risk of mortality.12 Putting these findings together suggests that one way to help Christian clients make sense of painful experiences is to engage their religious beliefs and perspective to facilitate meaning making (or a reconstruction of meaning).13 Doing so might result in seeing the experience in a new, more positive way, or it might result in them altering their religious worldview to better fit with their experience. Either way, having the opportunity to process the painful experience by engaging their Christian worldview can help reconcile discrepancies between their religious beliefs and their life experience.

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Christianity and Redemptive Reframing There are several key issues to consider when examining suffering from a Christian perspective. Here are just a few of them: ▶▶ How can a loving God let bad things happen? ▶▶ Is it a sin to be angry at God? ▶▶ If I’m doubting my faith, does it mean I’m not a Christian? ▶▶ Is God punishing or abandoning me? ▶▶ Why do some of the people at my church assume that if I’m suffering, it means I have done something to displease God? It would be presumptuous to think that I could even begin to provide answers for these challenging issues. For centuries, Christian theologians have written about and debated extensively the nature of spiritual struggles, good and evil, and the reason for suffering. These discussions and debates are ongoing today. Rather than suggest solutions, the purpose of this section is to inform therapists of potential key issues with which their Christian clients may be grappling. In addition, knowledge of biblical examples of suffering prepares therapists to most effectively engage in such discussions with clients. The Bible recounts the suffering of many individuals. These men and women were loved by God and endured suffering, not because they were out of the will of God, but because they were in God’s will. Jesus, the Son of God, was perfectly righteous, yet he was beaten and then put to death on a cross, a death willed by his Father and willingly chosen by Jesus. Job was also described as being without sin and loved by God, yet God allowed Satan to take everything from him with the exception of his wife and his own life. King David was anointed as the next king of Israel and then, for no fault of his own, he was hunted like prey for the next fifteen or so years by the current king, living in caves to survive. The apostle Paul was constantly facing hardship and perils, barely escaping with his life, and yet he was being obedient to God’s calling on his life. Although these stories do not answer the question, “Why do Christians suffer?” they do demonstrate the coexistence of people

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who suffer and a God who loves them. Indeed, immediately after telling his disciples how much God loved them, Jesus said, “In the world you have tribulation and distress and suffereing, but be courageous; I have overcome the world” (John 16:33 AMP). Many such scriptures promise God’s presence and help in the fire, rather than promising to keep us from the fire (Isaiah 43:2). Another theme found in scriptures is that of a divine and loving purpose for the pain and suffering we endure, even though this purpose is often difficult to understand. The prophet Isaiah put it this way: “‘For my thoughts are not your thoughts, neither are your ways my ways,’ declares the Lord. ‘As the heavens are higher than the earth, so are my ways higher than your ways and my thoughts than your thoughts’” (Isaiah 55:8–9). Perhaps this is one reason for the paradox of posttraumatic growth. Although the painful challenges we go through are not desired, they can result in beautiful gifts that could not have been received otherwise. An example of the loving intent behind suffering is found in the message the prophet Hosea delivered to the Israelites, “Therefore, I am now going to allure her [the Israelites]; I will lead her into the wilderness and speak tenderly to her. There I will give her back her vineyards, and will make the Valley of Achor [Trouble] a door of hope” (Hosea 2:14–15). Here we see God taking ownership for leading the Israelites into a painful situation, yet the purpose and meaning behind this action were loving. The trouble they experienced was to become the very passageway to hope and a new beginning. For Christians, trusting in God’s character and believing God has a loving intent behind everything helps them to find meaning and hope in the middle of painful trials. It is called “faith” because Christians don’t always or even usually know the why, but they are called to trust the One who does. Finally, it is helpful to know that the Bible is full of paradoxes, or what I call redemptive reframings. ▶▶ When you are weak, you are strong. So, delight in weakness because God’s power is most evident at those times (2 Corinthians 12:9–11).

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▶▶ God chooses the foolish things and calls them wise. This

way God receives the glory (1 Corinthians 1:26–29). ▶▶ Be perfect, but remember only God is perfect. There is no

need to strive because God’s perfection makes us perfect and righteous (Matthew 5:20; 2 Corinthians 5:21). These paradoxes show us that there is always more than one way to look at a situation. Looking at suffering from another perspective can help to “redeem the pain.”

Redemptive Reframing Skill-­Building Activities Redemptive reframing is a two-­step process, and the order of these steps is important. The first step is a sensitive client-­centered discussion about spiritual struggles and sacred losses during which the therapist mostly listens and empathizes. The second step is the introduction and use of meaning making and benefit finding. These activities help clients reframe their struggles by actively looking for ways God may be at work in their lives and the blessings that might be found from the situation.

Facilitate a Sensitive Discussion about Spiritual Struggles and Sacred Losses To facilitate this discussion we introduce the concept of spiritual struggles and sacred losses. Doing so not only provides a name for what some clients may be experiencing, but it also gives them “permission” to discuss these issues with us. Moreover, it can normalize and give expression to what may be considered taboo feelings for a Christian, such as anger toward God and doubt. We are not seeking (nor are we qualified) to engage in a complex discussion about theology. Rather, the goal is to help clients feel safe enough to acknowledge and explore potential spiritual struggles and sacred losses—losses that relate to their faith, relationship with God, and church community. Most clients are really asking, “Why me?” rather than, “Why did this happen?” Active listening,

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reflection, and empathy are therapists’ main activities during this discussion. Not all clients will experience spiritual struggles, but these issues should be assessed for their presence given their high correlation with depression. How to begin a discussion about spiritual struggles and sacred losses: As a Christian, going through difficult times and experiencing depression doesn’t just affect you emotionally and physically; it can also affect you spiritually. It’s normal during painful times to feel anger toward God, to wonder whether God has abandoned you or is punishing you, or to doubt things you have always believed to be true. Some Christians think they shouldn’t feel these things, but trying to suppress these feelings can lead to even more shame and suffering. Being honest with ourselves, God, and others is an important part of healing. Has this situation [name your client’s specific experience(s)] or your depression affected you spiritually? Have you experienced any of the feelings I described?

Some spiritual struggles can be framed as sacred losses, or losses that are related to the client’s faith and relationship with God. These losses can include a changed or diminished relationship with God, loss of relationships with other Christians, and change in religious beliefs (e.g., If I’m good, God will protect me from evil). Depending on our clients’ particular background and context, other questions we might ask about spiritual struggles and sacred losses include the following: ▶▶ Has your relationship with God changed because of your situation or depression? (Assess for anger, resentment, disappointment, fear, doubt, shame, guilt, etc.) ▶▶ What sorts of things are you questioning, if any, that you’ve never questioned before? ▶▶ Does it feel like God has abandoned you?

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▶▶ Does it feel like God is punishing you? ▶▶ Has your relationship with other Christians changed because

of your situation or depression? Again, the goal is simply to provide clients with a safe place to articulate spiritual struggles and losses they might be experiencing. Just hearing themselves describe their spiritual pain out loud can be healing in and of itself. The more detailed a picture we allow clients to paint for us, the better we are able to understand their worldview and avoid making assumptions or generalizations. This discussion also allows us to discern unhelpful or inaccurate beliefs that may be sustaining a client’s spiritual struggle, as well as ways the spiritual struggle may be helping to create or maintain the depressive episode.

Clinical Application Let’s return to the case about Maria and see how a therapist would have proceeded using the first step of the CCBT tool “Finding God and the Blessing in Suffering.” We’ll pick up where we left off at the beginning of the chapter. Maria: That’s exactly how I feel. When I needed God the most, he was nowhere to be found. What kind of God does that? How can he call himself “love” when he just sits there and lets us suffer? Sorry, I know that’s not very Christian of me to say. Therapist: I think it’s very honest of you to say, and courageous. A lot of Christians have felt the very same way you do. Maria: We’re not supposed to be angry at God. Therapist: That seems to be a common belief. I’m curious, did anyone in the Bible ever express anger toward God? Maria: Come to think of it, yes. I can think of a time when Moses got angry at God, yet it’s clear he and God had a very close relationship. I suppose God knows how we’re feeling anyway. It’s not like it’s a secret.

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Therapist: How has your relationship with God changed since the abuse? Maria: When he first started hitting me, it drove me closer to God. I spent a lot of time praying and listening to worship music. But after the years went by and nothing changed, I started to feel like God didn’t hear me or that he didn’t care. I felt—I don’t know—rejected. Therapist: That makes sense to me. How did things go after that, after you felt rejected? Maria: I found myself withdrawing, spending less time praying and listening to music, and skipping church. It’s not that I wanted to walk away from God, it’s just that doing those things hurt because it reminded me that God didn’t seem to care about me. A one-­sided relationship is painful. Therapist: It sure is. Did things change between you and your Christian friends, too? Maria: Yes, I already couldn’t talk about the abuse with them, and now I felt like I couldn’t talk about what was going on with me spiritually. I withdrew from them because that was easier than pretending everything was okay. Therapist: It was like a double loss for you: your relationship with God and your relationship with your faith community. Maria: [begins crying] I’ve never talked about this with anyone. I was so ashamed to be feeling this way. I’ve opened up about the abuse over the last three years, but I’ve never shared how things are between me and God. Therapist: I’m so glad you’re able to share this with me, Maria. I think it’s an integral part of your healing and recovery from depression. I feel honored to be part of this journey with you. Maria: I really want things to be right between me and God again. I miss the closeness we used to have. I just don’t know how to get there.

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Redemptive Reframing through Meaning Making and Benefit Finding The second step of redemptive reframing is helping clients make meaning of and find potential benefits from their painful experiences. To normalize their experience and to facilitate meaning making, it can be helpful to examine the painful trials that individuals in the Bible suffered, how they managed these trials, and the ultimate result of enduring the suffering. The advantage of having these stories to reflect on is that they have endings, whereas the client is still in the middle of his or her story. Seeing an end and a redemptive purpose for other people’s suffering offers hope for clients.

= For everything that was written in the past was written to teach us, so that through the endurance taught in the Scriptures and the encouragement they provide we might have hope. —Romans 15:4

How to use biblical stories of suffering to facilitate meaning making: Many people in the Bible endured painful trials. Can you think of any examples? [Depending on how the client responds, you might discuss the story of Job, Abraham and Sarah having to wait ten years for their promised son, Daniel and the lion’s den, David and the threats on his life after being anointed to be king, Jesus’s suffering and death, Steven who was stoned for his faith, the perils of the apostle Paul, or other examples.] It’s hard to find anyone in the Bible who didn’t undergo some sort of suffering and loss. What do you make of this? Does it bring you any comfort? Can you relate to any of these stories of suffering? If so, how?

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The purpose of this discussion is to illustrate that being a Christian doesn’t mean a pain-­free life, as well as to explore God’s provision in and purpose for the suffering these individuals endured. The stories, many of which Christians learn in Sunday school, provide role models for coping with pain and the seeming absence of God. A discussion like this also legitimizes anger toward God and doubt. Discussions about scriptures that discuss suffering and trials can also facilitate meaning making. What do you think of this verse found in James? “Consider it pure joy, my brothers and sisters, whenever you face trials of many kinds, because you know that the testing of your faith produces perseverance. Let perseverance finish its work so that you may be mature and complete, not lacking anything” (James 1:2–4). Or what comes up for you when you read this verse in Lamentations? “For no one is cast off by the Lord forever. Though he brings grief, he will show compassion, so great is his unfailing love.  For he does not willingly bring affliction or grief to anyone” (Lamentations 3:31–33).

In addition to scripture, many Christian speakers and authors have tackled the subject of suffering and spiritual pain. Clients can make use of these resources as well. For example, Phillip Yancey, C. S. Lewis, Elisabeth Elliot, and Timothy Keller have written excellent books on spiritual suffering and grief.

Finding God and the Blessing in Suffering By this point in the session, the client has had a chance to express his spiritual struggles and to examine struggles experienced by “heroes of the faith.” If we have done our job well, the client feels safe and heard, his emotions and experiences have been normalized and legitimized, and he has explored the idea of suffering in the context of his Christian teachings. Now is the time to discuss the paradox of posttraumatic growth, which presents a springboard for developing a new perspective about his own pain and suffering using his religious resources.

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Sometimes this step should be saved for another session. Clients may need to explore their spiritual suffering for several sessions before they are ready to consider positive changes that might have occurred or could occur as a result of the painful experience. We can begin by explaining the concept of posttraumatic or stress-­related growth, broaching the subject in a sensitive and flexible manner. To do so, we can ask a broad, nonleading question, such as, “What changes have you noticed since X situation occurred or since you became depressed?” This question invites clients to discuss negative as well as positive changes, including changes that were expected and those that were unexpected. We listen for statements reflecting a positive change in areas such as their character, outlook in life, relationships, career, dreams, religious identity, and capacities. The goal of this discussion is to help clients use their religious beliefs to (1) identify where God’s active, loving hand might be found in their situation (i.e., meaning making), and (2) what blessings may have come or will come from this painful situation (i.e., benefit finding). Clients often find that at least some if not all of their pain is “redeemed” by assigning it meaning and finding its purpose. Here are some follow-­up questions that invite our clients to consider a redemptive reframing of their suffering: ▶▶ Have there been any unexpected blessings as a result of what happened? If so, what are they? ▶▶ In what ways, if any, has your faith been helpful or comforting to you during this situation [or your depression]? ▶▶ How do your religious beliefs [beliefs about God, love, grace, etc.] help you to make sense of what happened to you? ▶▶ Are you familiar with the poem “Footprints in the Sand” by Mary Stevenson? Can you summarize the message in the poem? What does it mean to you? Looking back, can you see any times where God might have been carrying you? ▶▶ Romans 8:28 says that God makes all things work together for our good. Do you believe that? How might God be using or planning to use this situation in your life for good?

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▶▶ What have you learned about yourself through this situa-

tion? About God? About your faith? ▶▶ How do you think this perspective [or these blessings] will

help you when you encounter difficult situations in the future? You can also ask clients to reflect on one or more of these questions by journaling about it over the next week. In the next session, follow up with them to see where their reflection led them and reinforce any redemptive reframing that might have occurred.

Clinical Application Now let’s watch how the therapist helped Maria use the second step of the CCBT tool “Finding God and the Blessing in Suffering” to help reduce her sadness and spiritual pain. Therapist: When we go through traumatic events, they shake up how we see the world. It can be hard for us to fit the experience in with what we have always believed. Sometimes we change what we believe to fit the experience. Other times, we are able to look at the experience from a different perspective so that it fits better with our beliefs. I wonder if it would be helpful to look at the lives of some of the people in the Bible who suffered painful events. Perhaps their stories can help you make more sense of your own. Maria: Okay, we can try that. Therapist: Earlier you talked about how God rescued the Israelites from the Egyptians. I’m not too familiar with that story. Can you tell me more about it? Maria: Sure. The Israelites were slaves to the Egyptians, who beat them and treated them very badly. After they prayed for deliverance, God sent Moses and Aaron to inflict the ten plagues on the Egyptians. Finally, after the plague that killed all of the Egyptians’ firstborn sons, Pharaoh let the Israelites go.

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Therapist: How long were the Israelites in slavery? Maria: I think it was quite a while. Let me check. [Looks up the passage in Exodus on her phone and reads it silently.] Wow, it says they were slaves for four hundred years! I knew it was a while, but that’s a long time to be praying for deliverance. A lot longer than I prayed for deliverance. Therapist: It’s hard to understand why it took God so long, isn’t it? Maria: Yes, it is. I know he rescued them so he could take them to the Promised Land. So he did love them because he had good plans for them. It just took a long time for him to act for some reason. Therapist: Are there any other parts of the exodus story that were confusing or painful for the Israelites? Maria: Yes, shortly after the Israelites left Egypt, Pharaoh changed his mind and sent the entire Egyptian army after them. The army almost succeeded, too, because when they caught up to the Israelites they had nowhere to flee. The Red Sea was in front of them, and the army was behind them. At the very last minute, God split the Red Sea, and they were able to escape. Therapist: That must have been terrifying for the Israelites, and confusing, too. Why do you think God waited until the very last minute to split the Red Sea? Maria: Well, the Egyptians followed the Israelites into the sea and then God closed the sea and they all drowned. Oh! I never saw it like this before, but if the Egyptians hadn’t been very close behind, they couldn’t have been wiped out when the sea closed back in. By waiting until the very last minute, when it looked like the Egyptians would win and make them slaves again, God was able to destroy them completely! In retrospect,

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that was a much better plan, but yes, I’m sure the Israelites were very scared and confused. I know I would have been feeling that way. Therapist: It probably looked like God didn’t care about them. Maria: Yes, they said it would have been better to stay slaves. They accused God of bringing them into the wilderness just to kill them. I think it was hard for them to trust God because they didn’t see the whole picture. Therapist: Do you think you see the whole picture of your story? Maria: When I think about it in light of this story, no, probably not. Maybe there was a reason it took twelve years for my exodus. God might have let me stay for some reason that was actually for my good. I’ve certainly never thought about it like that before. Therapist: I wonder, if you were to look at the bigger picture, do you think there has been anything positive that has come from that awful time in your life? Maria: This might sound weird, but for years I’ve had this picture of myself shackled in leaden chains and covered in heavy mud. Therapist: Sort of like a slave? Maria: Yes, like one of the Israelites. Every time I see that picture of myself I get angry, angry at God for not helping me get out of the chains. But now I’m starting to wonder if maybe there was a purpose for those chains, for that heavy mud. Therapist: What sort of purpose, do you think? Maria: Maybe those leaden chains and that mud, maybe they are the very things that have been building my muscles. You know, like how an athlete lifts heavy weights to become strong.

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Therapist: So those things that you saw as enslaving you might actually have been used to make you a strong warrior? Maria: Yes, a strong warrior because now I can help other women in abusive relationships. Maybe God did hear me all those years, but maybe he knew I’d be stronger the longer I wore the chains. He did protect my life and deliver me, just not in the timetable I wanted. Maybe that was for the best in the long run, you know, in the bigger scheme of things. Therapist: You look relieved as you say this. Maria: I feel relieved. I’ve been angry at God for a long time, but now I’m starting to see that he really does love me and his way of doing things is good, even if I can’t understand it at the time. I can trust a God I know loves me. When Maria returned the following week, she had asked one of her female coworkers out to a movie over the weekend, the first time she had been out with a friend in years. She had also slept eight hours most nights that week and reported connecting with God again in prayer. In using the tool of redemptive reframing, the therapist began by creating a safe space for Maria to voice her spiritual struggles, which she did for the first time, and also validated her pain. The therapist then intentionally used Maria’s religious language and the biblical example Maria had referred to when talking about the abuse she endured. Through gentle Socratic questioning, she helped Maria to draw upon the biblical exodus story to make meaning and find purpose in her own struggles. Maria’s picture of herself and her interpretation of God’s long silence changed dramatically, and she came to the conclusion that she had been equipped to help other women in abusive relationships. This is the meaning and blessing from her suffering Maria needed to find before she could move forward in her life and her relationship with God. Realizing she could trust in God’s goodness

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and sovereignty freed her to begin to trust others and engage in life again. Redemptive reframing through meaning making and benefit finding, rooted in Maria’s Christian worldview, was a critical piece of her recovery from depression.

= Tool Summary Clients can engage in redemptive reframing of the struggles they face through the following activities: ▶▶ A sensitive discussion about spiritual struggles and

sacred losses ▶▶ Searching for and creating meaning from their

suffering ▶▶ Engaging in benefit finding—finding God and the

blessing in suffering

Chap t er 7

Reaching Out and Connecting Let us consider how we may spur one another on toward love and good deeds, not giving up meeting together, as some are in the habit of doing, but encouraging one another—and all the more as you see the Day approaching. —Hebrews 10:24–25

Meet Shawn

S

hawn is a nineteen-­year-­old, single, Christian African American man who moved across the country to begin college seven months ago. One night shortly after classes began, Shawn felt very ill and asked a friend to drive him to the ER. Diagnostic testing revealed that he has Type 1 diabetes. A former high school athlete, Shawn had always been in great health. This diagnosis shook him deeply. He was referred for psychotherapy by his endocrinologist, who reported that although Shawn’s blood work had been within the recommended range for quite some time, he continued to report not feeling like himself and experiencing low mood and apathy. This excerpt is from his second session of CCBT. Therapist: Thank you for completing the activity monitor last week. From what you recorded, it looks like when you’re not in class, you mostly play video games or sleep. Is this different from how you spent your time before you moved away for college? Shawn: Very different. I used to play hockey three nights a

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week. When I wasn’t on the rink, I was in church practicing with the band. I played the guitar. On weekends I was usually out with my buddies from youth group. Therapist: Have you done any of those things over the last few months—played hockey or the guitar or gone to church? Shawn: No, I’ve gone to a local church a few times, but it’s not that fun sitting by myself. I can’t say I’ve tried that hard to meet anyone, though. Occasionally, I’ll pick up the guitar at home, but I’m not part of a band now. Haven’t been on the rink since my diagnosis either. Therapist: What is it about the diabetes that keeps you from doing the things you used to love? Your endocrinologist says you are managing it very well. Shawn: I just feel different from everyone else. Life is complicated now; I can’t even go out for a simple meal without having to worry about this disease. I used to be fun to be with, spontaneous. Now I feel like a burden, and I hate feeling that way. It’s easier to keep to myself. Shawn’s image of himself and his passion for life have plummeted since he was diagnosed with diabetes. Although diabetes and depression have some similar biological underpinnings, Shawn’s symptoms seem to stem from a mood disorder rather than from diabetes, which notably he is managing well despite his low mood and motivation. Shawn would benefit from a therapeutic approach to help him challenge the conclusions he has drawn about his identity and usefulness in the world, and one to help him reengage with his passions. Challenging these conclusions may be most effectively accomplished through increasing meaningful activity and spending time with people. His faith and previous involvement in youth group suggest a CCBT approach using the “Reaching Out and Connecting” tool might be particularly helpful. This tool equips clients with

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the motivation and skills necessary to engage in their Christian community as a strategy for combating depression.

Scientific Support for Reaching Out and Connecting One of the strongest and most consistently documented relationships in health psychology is the positive and protective relationship between social support and health. Simply put, people who feel loved, valued, and cared for by others are healthier, happier, and live longer.1 They also recover from illness more quickly, deal with stress more effectively, and are less likely to be negatively impacted when going through difficult life situations. The effects of social support seem to be at least in part due to the impact it has on endocrine, cardiovascular, and immune functioning.2 Social support can be provided by spouses, family, friends, colleagues, church and community members, and even pets.3 There are at least three different types of social support: practical or tangible assistance (e.g., being given a ride to the doctor’s office), emotional support (e.g., someone to listen when you have a bad day), and informational support (e.g., being taught how to do something). The benefits from social support need not be actually provided—just believing that such help and support is available, or thinking about the support one has, exerts a beneficial effect.4 Notably, the benefits are also contingent on how well one is able to obtain and use the social support they have available to them.5 Those who are depressed may be less adept at accessing support when they need it. When we feel part of something larger than ourselves we are better able to manage stress and the challenges of life. 6 Religious individuals may have a double advantage here in that they have the opportunity to be part of a church community and experience a sense of belonging to a God who loves them and has a plan for their lives. Indeed, research shows individuals who report greater religious involvement often enjoy greater social support. This may be

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one of the reasons religious involvement is related to less depression and better health outcomes.7 One of the strongest statistical relationships in the religion and health literature is the association between religious attendance and mortality. The more frequently people attend religious services, the longer they live.8 This association holds fast even after accounting for other variables that might explain this relationship, such as health status, social economic status, social support, and mental health. Being in a religious environment and part of a church community appear to be life-­promoting. Another type of social support is spiritual support, also known as church-­based support, which helps people maintain, deepen, and live out their faith on a daily basis.9 There seems to be something unique to spiritual support compared to other types of secular (nonchurch-based) support. Several studies have shown that emotional support provided by church members reduced the negative effect of financial stress on health and the negative effect of functional disability on sense of personal control. In contrast, emotional support provided by people in secular social networks did not have these beneficial effects.10 Of note, as in any other context, not all relationships among church members are positive and supportive. It is important for therapists to assess for this possibility because interpersonal conflict among church members has a negative effect on well-­being.11 It may also be a reason for a client’s change in religious involvement, particularly involvement of a social nature.

Christianity and Reaching Out and Connecting There are at least two key teachings in Christianity about community and supporting others that are useful for mental health providers to be aware of. First, the scriptures encourage Christians to regularly assemble as a community. In the book of Hebrews, Paul admonished believers to not “giv[e] up meeting together,” but instead to continue to fellowship with one another in order to pro-

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vide encouragement and to “spur one another on toward love and good deeds” (Hebrews 10:24–25). The early church began not in large cathedrals, but in people’s homes, as small groups of believers who met often on a daily basis to “break bread” (i.e., share a meal) with one another (Acts 2:46). Being an active part of a community of faith was one of the ways they practiced being the “family of God,” which is how Christ referred to his followers—brothers and sisters and sons and daughters of God. Second, the scriptures encourage Christians to bear one another’s burdens as Christ bore their burdens (Galatians 6:2). Burden bearing can take the many forms of social support, such as providing practical, tangible resources or meeting another’s emotional needs by being a shoulder to cry on or putting up with his or her quirks and faults (Ephesians 4:2). Burden-­bearing is another way the church practices being a family, caring for one another as if they are related by blood. Indeed, the Bible teaches that the way non-­ Christians should be able to identify individuals as Christians is by the way they love one another, both those in and outside of the church (John 13:35). To fulfill this command necessitates living in close and continual fellowship with other Christians.

Reaching Out and Connecting Skill-­Building Activities The next section describes how to use the Reaching Out and Connecting tool. This tool works to combat the depressive tendency of social isolation by exploring ways for clients to be involved in a religious community and in religious activities.

Rationale for Reaching Out and Connecting The tools presented in this primer so far are cognitive in nature, meaning they function to transform a client’s emotional state by modifying unhelpful and inaccurate thinking. Reaching Out and Connecting is a behavioral tool. It targets depressed mood by reducing depressive-­maintaining behavior (e.g., avoidance, inactivity)

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and increasing pleasant behavior and social activities. It is helpful to remind clients of the CBT model and the bidirectional relationships between our thoughts, behaviors, physiology, and emotions, and to let them know that this tool will be specifically working with the behavior-emotion link. As a reminder of the relationship between behavior and emotions, we can ask clients for an example of an activity that brought them joy in the past, as well as an activity that dampened their mood. If clients are unable to think of examples, we can supply one ourselves. Be sure to also discuss inactivity as a type of depression-­ maintaining behavior. Avoiding people and activities because one feels depressed leads to greater isolation thereby, worsening one’s mood. This becomes a vicious negative cycle.

Exercise: Activity Monitor An activity monitor is a standard CBT tool used to gain an accurate understanding of how clients are spending their time, both for the benefit of the therapist and the client. For this assignment, clients record all of their daily activities, trivial and non­trivial, hour by hour, from the moment they wake up until retiring to bed that evening. They also record their emotional state during each time period. They then bring the completed monitor with them to their next session. When reviewing the completed monitor with our client, we identify patterns between the various types of activities they participated in and their subsequent emotional state. This exercise helps to illustrate the CBT model and provides a springboard to discuss how behavioral changes, particularly increasing social activities, can help improve their mood. This strategy is also called behavioral activation and is effective in reducing symptoms of depression. It is likely that there are not many positive activities listed in the activity monitor. We can explain that the goal is to change this fact by identifying and then engaging in more pleasant and social activities over the next few weeks. Reviewing the activity monitor is also a good time to inquire about our clients’ current level of exercise

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and nutrition. We can remind them of the connections between our physiology and mental well-­being, as well as the research that shows the mood enhancing effects of exercise for people with mild to moderate depression.12 When our bodies are healthier, we feel more energized (and often experience a positive boost in mood); this in turn can increase both our desire and our ability to socialize. As such, some form of enjoyable movement or exercise is an excellent activity to add, especially if it can be done with someone else.

Religious Rationale: Walking by Faith What distinguishes this CCBT tool from the CBT principle of behavioral activation is both the religious motivation for behavior change and the type of behavior encouraged—religiously based social behaviors. Christian clients may find the motivation to change by drawing upon a religious rationale for engaging in activities and making social connections. Changing one’s behavior, whether it be by increasing pleasant activities, attending church, or actively engaging with members in a faith community, is difficult for someone who is depressed. Apathy, fatigue, and social withdrawal are characteristics of depression. Yet, both CBT and Christianity advocate for social and behavioral engagement. One way to frame this dilemma for a Christian is to relate it to the biblical concept of “walking by faith and not by sight” (2 Corinthians 5:7). Christians don’t believe in God because they can see God, but because they have faith that he exists. Likewise, they choose to engage in behaviors congruent with their Christian values and belief system (e.g., worship, forgiveness, generosity) based on what they believe God wants them to do, not based on what they necessarily feel like doing. This principle can be applied to increasing activity in general and to engaging in religious behaviors, such as fellowshipping with other Christians. The concept of walking by faith is strongly connected to the CBT principle of behavioral activation—engaging in activities despite feeling depressed with the intent of changing one’s mood through changing behavior. The difference between walking

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by faith and behavioral activation is the motivation driving the decision to act before one feels better.

Exercise: Increasing Involvement in a Faith Community Now it is time to explore if your client would be interested in being more involved in a faith community. Some Christian clients will already be part of a church community and greater involvement is both welcomed and relatively easy to accomplish. However, when experiencing depression, involvement in a religious community can become more sporadic or peripheral. Others may have chosen not to go to church for reasons that may or may not be related to their depression, such as conflict with other church members, spiritual struggle or hurt, or disagreement with the doctrine of a particular church. Reaching Out and Connecting is not a prescriptive activity because it is not ethical to tell someone to go to church. The primary goal of CCBT is treating depression, not increasing religiousness, although CCBT may have that secondary effect on some clients. Like all tools and activities, engagement in a faith community is an option collaboratively explored with clients as a potential helpful tool in reducing symptoms of depression. Reaching Out and Connecting is more than just attending church to receive support from others. Rather, clients are encouraged to connect in part by providing support to someone else. This involves identifying and then contacting someone in their faith community whom they can support with their time, resources, and prayers. This is likely to result in increased social support, as well as generosity, both of which are shown to improve mood.13 There are numerous ways clients can get involved in a faith community. Beyond attending weekly church services, they can join a small group (sometimes called a life group or Bible study group), attend events put on by various specific ministries in the church (e.g., women’s ministry, singles’ ministry), sign up for a retreat or workshop, attend a church dinner, participate in community service sponsored by the church, have a conversation with one of the spir-

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itual leaders, volunteer at the church (e.g., greeter, usher, nursery worker), join the choir, or meet one-­on-­one with a member of the church. Suggested dialogue for how to discuss Reaching Out and Connecting with your client: The research shows that spending time with people, though more challenging when depressed, is an effective way of improving your mood. As a Christian, you have the opportunity to spend time with and support people who share your faith. In fact, the Bible calls Christians “the family of God” and encourages them to fellowship with and care for one another. Would you like to explore ways to improve your mood by reaching out and connecting with your faith community?

Depending on the client’s answer, you might ask some of the following questions: ▶▶ Are you currently attending a church? How often do you

attend? ▶▶ Are you involved in any other faith-­based activities, such as a

Bible study or small group? ▶▶ Has the frequency or nature of your participation changed

since becoming depressed? ▶▶ Have you experienced conflict with members of your

faith community? Has this played a role in your change in involvement? ▶▶ Is there someone in your faith community you feel particularly

close to?

If our client is not currently involved in a faith community, we can explore if she or he used to be, why this changed, and if she or he would be interested in becoming part of a faith community again. If our client is interested in becoming more involved, we then brainstorm with him or her ways to do this. This is also an exercise

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that can be assigned for home practice. Most churches have websites that clients can peruse to find this information. It’s important to have people we can lean on, but it’s also important that we are someone whom others can lean on. Caring for others is one way to get our minds off of our own troubles and allows us to play an active role in the family of God. ▶▶ How much time do you spend with members of your faith

community? ▶▶ Is there anyone that provides you with support on a regular

basis? ▶▶ Is there anyone that you are providing support to on a regular

basis? ▶▶ If not, what do you think about identifying someone in your

faith community for whom you could pray, meet with, and support on a regular basis?

Ask interested clients to identify at least one person in their faith community who they could both support and from whom they could potentially receive support. For clients who are unable to think of anyone, spend time discussing how they might be able to find such a person. Those not part of a faith community or not interested in being part of one can identify someone else in the community at large. Ideally, this person is not a family member and lives locally so that in-­person visits are possible. The next step is for the client to make contact with this person and ask if she or he would be willing to spend time with the client or talk on the phone about once a week. We can role play this conversation with the client to increase her comfort level for reaching out with this request. In the next session, we follow up with our client to see if she made contact with this person. If no one was identified or contacted, we explore the barriers our client faced and engage in problem solving

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so that she can try again this week. We also review the rationale for this exercise, how it can help improve mood, and if and how our client sees this fitting within her religious worldview and value system.

= I beg you—I [Paul], a prisoner here in jail for serving the Lord—to live and act in a way worthy of those who have been chosen for such wonderful blessings as these. Be humble and gentle. Be patient with each other, making allowance for each other’s faults because of your love. —Ephesians 4:1–2 The Living Bible

Clinical Application Now we’ll return to the case about Shawn and see how the therapist used the CCBT Reaching Out and Connecting tool to help him reduce his sadness, isolation, and sense that he has less to offer others now that he has diabetes. At this point in the session, Shawn and his therapist have finished reviewing his completed activity monitor. Therapist: Being diagnosed with diabetes has really done a number on the way you see yourself and your usefulness in the world, hasn’t it? As a result, you have withdrawn from people, including your church community, and the activities that used to bring you joy. We know from the research that spending time with people, both receiving support and giving support, and doing things you like improve your mood. In our CBT model, this is the behavior-­emotion link: What we do influences how we feel. Shawn: To be honest, most of the time I don’t feel like doing much of anything.

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Therapist: I’m sure you don’t, that’s part of depression, and it’s what makes this behavior-­emotion link challenging. To feel better, you need to engage in pleasant activities and spend time with people, but when you’re depressed it’s hard to find the energy and motivation to do those things. It can feel like a catch-­22. Shawn: It is a catch-­22. It’s easier to be depressed. Therapist: It might be easier, but I also know you’re tired of feeling miserable. Remember how we discussed that your Christian belief system might be a helpful resource for you in therapy? What do you think about exploring how your faith might help you to find the energy and motivation you need to get started? Shawn: I’m open to anything that might help at this point. Therapist: Does Christianity have anything to say about people doing certain things even though they don’t feel like it? Shawn: Sure, there are lots of things we might not feel like doing, but we try to do anyway because that’s what God wants. Therapist: Can you think of a time when you did something you didn’t want to do because you wanted to please God? Shawn: There were times when I played in the band at my old church that I didn’t feel like singing or praising God, but I’d do it anyway. Come to think of it, I was always glad I did because once I started, I ended up enjoying it. It’s like the feeling of wanting to sing came afterward. Therapist: That’s a great example of the feeling coming after, or as a result of, the behavior. That sounds a lot like the biblical principle of “walking by faith and not by sight.” I think it could probably also be phrased, “walking by faith and not by feelings.” What do you think?

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Shawn: Yeah, that’s a good way of putting it. I know the Bible says God will help us if we ask him. Maybe I could ask God for the energy and motivation to get started even though on my own I don’t feel like it. Therapist: It sounds like that might be very helpful for you. I’m wondering, given how important being involved in church was to you—playing in the worship band and hanging out with your buddies from youth group—what you think about becoming more involved in a church here. You could have a church family here like you did back home. Shawn: It would probably be good for me. I do miss it. Therapist: I know you say you’ve gone a few times, but you sit alone. What do you think would help you to meet people and get more involved? Shawn: I suppose I could start by actually getting there every Sunday. It’s a push to make myself get up early, but I could make it more of a priority. I’m not sure that’s going to change how I feel, though. It’s not exactly a social event despite being surrounded by hundreds of people. Therapist: Is there anything you could you do to change that? Shawn: I guess instead of sitting by myself at the back, I could sit beside someone. You know, say hello, introduce myself. Therapist: I wonder if there are others who are feeling the same way you do, sitting by themselves, feeling alone despite being surrounded by hundreds of people? Shawn: I hadn’t considered that before, but with a crowd that large, I’m sure there are. Maybe I could look around and find someone else sitting by themselves and then sit beside that person. Who knows, maybe I could end up making him feel less alone.

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Therapist: That’s a great idea! You never know what someone else is going through. That person might need some encouragement and support, but you’d never know it to look at him or her. Just like no one would know by looking at you that you have diabetes and how challenging you are finding this diagnosis. You’ve actually just hit upon one of the CCBT tools I think would be helpful for you. It’s called Reaching Out and Connecting, and it helps improve your mood through engaging with your faith community and supporting other people in that community. Shawn: And doing these things before I actually feel like doing it? Therapist: Yes, exactly, the walking-­by-­faith-­not-­by-­feelings concept. Over the next few weeks, what do you think about identifying someone at your church whom you could make contact with on a regular basis, someone you could support and in turn who could support you? Shawn: Basically make a friend at church? Therapist: Right, someone you can devote some time and energy to, someone you might pray for and who in turn might pray for you. Shawn: It would be nice to know I could make someone else feel less lonely. It might also help me get my mind off of my own problems. Therapist: I think it would also show you just how much you still have to offer the world, regardless of your diagnosis of diabetes. Besides striking up conversations during the Sunday service, how else might you get more involved in your church community? To have other opportunities to meet people? Shawn: I could see what groups they offer. Sometimes churches have a college ministry, sort of like youth group, but for people in college. They might also have Bible study groups.

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Therapist: Those sound like good places to make friends. Who knows, maybe they’ll even need a guitarist in their band. What specifically can you do before we meet next week to reach out and connect? Shawn: Well, like we discussed, I can sit beside someone who is sitting alone on Sunday and try to talk with them. I can also look on the church website or maybe in the church bulletin to see what groups or ministries the church offers. Therapist: This is a great plan. I’m looking forward to hearing how it goes and whose day you make better by reaching out and connecting. Over the next few weeks, Shawn sat beside others sitting alone in the Sunday service and intentionally struck up a conversation with them. One Sunday, he met a man his age who invited him to a college ministry event. He and this individual have met a few times for lunch since then, and Shawn has opened up a little about his diagnosis and the challenges he has faced this year. He has also been able to support his new friend who has been having some family problems. Reaching out and connecting to his faith community enabled Shawn to feel less lonely and demonstrated his value to others. He was able to use this experience to challenge his negative beliefs about his identity and usefulness as a result of having diabetes. His Christian belief system also assisted him in finding the motivation and energy necessary to engage in depression-­reducing behaviors before he felt like doing so.

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= Tool Summary Clients can engage in reaching out and connecting to combat the depressive tendency of social isolation through the following activities: ▶▶ Completing an activity monitor ▶▶ Finding ways to be involved in a religious community

and in religious activities

Chap ter 8

Letting Go and Letting God Acceptance and Forgiveness

“Do not judge, and you will not be judged. Do not condemn, and you will not be condemned. Forgive, and you will be forgiven.” —Luke 6:37

Meet Hee Jung

H

ee Jung is a thirty-­one-­year-­old Asian Christian Protestant woman who had a miscarriage two years ago. She was five months into her pregnancy at the time. She and her husband both grieved deeply for months after the loss. With time, her husband’s grief lessened, and recently he has brought up the idea of trying to have another baby. In contrast, Hee Jung’s sadness has not abated, and she has become increasingly irritable and withdrawn from her husband and her friends. She lashes out each time her husband suggests they try getting pregnant. She doesn’t like the woman she has become and is starting to lose hope that she’ll ever feel like herself again. The following excerpt is from her fifth session of CCBT. Hee Jung: Just like everything else in my life, I was so careful to do everything right. I started the prenatal vitamins six months before I got pregnant, didn’t have a drop of alcohol, exercised in moderation, and gained exactly the amount of weight my doctor told me I should gain. Then around month four, things got crazy at work. We were about to lose a contract with our

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biggest client. I had to work overtime most nights. I should have known better. If I hadn’t let myself get stressed about work, I wouldn’t have lost my baby. Therapist: Is that what your doctor said, that you miscarried because you were stressed? Hee Jung: No, she says she doesn’t know why it happened. That sometimes these things happen and there’s no good explanation. Honestly, though, who does she think she’s kidding? We all know stress has a negative impact on the body. It’s my fault I lost Jia, and I’ll never forgive myself for it. Therapist: I’m really sorry you lost your baby girl, Hee Jung. It’s devastating to lose a child. And I can understand why, if you believe it’s your fault, you are in so much pain and so angry. Hee Jung: You know what makes this even worse? I prayed over her every morning and every evening for five months, asking God to keep her healthy and safe. The Bible says God will look after us and that he loves us, but he sure didn’t demonstrate either of those things for me or Jia. I’m human and I do everything in my power to keep my promises. God has unlimited power; he has no excuse for not keeping his. Hee Jung is still deeply distressed over the loss of her baby girl. Although grief is a normal response to loss, the fact that her grief has not lessened in intensity for two years and is accompanied by symptoms of withdrawal, irritability, and extreme guilt suggests that Hee Jung is also experiencing depression. Compounding, and perhaps maintaining, her grief and depression is her belief that she is to blame for the miscarriage and that God failed to keep his promises to her. She reports that her spiritual distress makes it “even worse.” Clearly, her anger at God and spiritual distress need to be acknowledged and addressed in order for her to begin to heal. CCBT is a therapeutic approach that can assist Hee Jung in exploring her spiritual and psychological pain. The CCBT tool “Letting

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Go and Letting God” employs acceptance and forgiveness from a Christian perspective for reducing depressive symptoms. This may be a particularly helpful tool for Hee Jung, who still ascribes to a Christian worldview, but is struggling to accept her tragic loss and a God whose actions do not fit with her interpretation of scripture.

Scientific Support for Acceptance and Forgiveness Despite our best efforts in life, not only we will be hurt and treated unfairly, we will also be the cause of pain and injustice in other people’s lives. The negative emotions that can arise from these situations, such as anger, bitterness, and resentment, are toxic to our mental and physical health.1 Teaching clients strategies for effectively responding to hurt, relinquishing toxic emotions, and generating a positive emotional and cognitive state is a central focus of psychotherapy. In this chapter, we explore two such psychological strategies, which are also spiritual practices in Christianity: acceptance and forgiveness. Acceptance is the capacity to be willing, open, and receptive to reality in the present moment.2 Most types of psychotherapy require clients to summon the courage to face (i.e., accept) their painful realities in order to move toward a life worth living.3 In some therapies, acceptance is the bedrock of the approach, such as in Dialectical Behavior Therapy,4 Acceptance and Commitment Therapy,5 and the 12-­step programs. Likewise, many spiritual traditions teach that acceptance of a painful reality, as opposed to denial, distraction, or numbing, is the pathway to peace and healing. Although acceptance is a form of surrender, acceptance does not necessarily mean giving up, being passive, or agreeing.6 Indeed, spiritual surrender is an active, spiritually motivated form of acceptance in which the individual intentionally lets go of something (e.g., striving, control, a desired outcome) and lets God be in charge of the situation. Paradoxically, the spiritual practice of surrendering control to God often results in an increased sense of control,

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although this outcome is not the motivation for surrender.7 Unlike denial and passivity, spiritual surrender is correlated with stress-­ related growth, less depression, and improved quality of life.8 Forgiveness is another tool for dealing with life’s hurts and injustices. Although forgiveness has been defined in a number of ways, most definitions have at least two criteria in common. The first is an emotional component; that is, a shift from experiencing negative emotions (e.g., anger, resentment, bitterness) to positive, other-­ focused emotions (e.g., love, compassion, peace). The second is a decisional component, or a choice to change one’s beliefs, attitudes, and perception regarding a transgression and transgressor.9 Forgiveness may also entail a behavioral component, such as no longer avoiding someone or enacting revenge or engaging in some sort of compassionate action. Forgiveness is good for us. It is associated with a decrease in depression, hostility, and anxiety; improved relationships; and greater well-­being, self-­esteem, hope, and long-­term happiness.10 Self-­forgiveness is particularly highly correlated with well-­being.11 Forgiveness, like acceptance, is a capacity that needs to be developed.12 Several psychological approaches have been developed to help clients enhance their capacity to forgive.13 A meta-­analysis of fifty-­four studies revealed that individuals who received a forgiveness intervention were 71 percent more likely to forgive compared to those who received an alternative therapy or no treatment. Length of treatment, empathizing with the offender, and making a commitment to forgive seem to be critical components of forgiveness interventions.14 Not surprisingly, research has found associations between religion and forgiveness. Some evidence shows that people who are religious also tend to be more forgiving and draw upon their religious beliefs when forgiving.15 Other research also suggests that those who have deeply internalized their religious beliefs may be more receptive to forgiveness interventions.16

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Christianity and Acceptance and Forgiveness Acceptance, trust, and forgiveness are prominent themes found throughout the scriptures. Familiarity with several fundamental teachings in Christianity on these concepts will better inform the use of the “Letting Go and Letting God” CCBT tool. For a biblical understanding of trust and acceptance, it is helpful to know how God is portrayed in the Bible. God is described as sovereign (i.e., the head of all of creation) (2 Samuel 7:22), creating and fulfilling his own plans for people’s lives (Job 23:14), and thinking and acting in ways that are higher than and not fully understood by mortals (Isaiah 55:9). At the same time, God is also described as kind, loving, and intimately concerned with each individual’s life (1 John 4:8). As such, the power that God exerts and the plans he executes are characterized in Christian teachings as being loving and in humankind’s best interest. Second, it is useful to know some of the ways scriptures admonish Christians to trust and accept: ▶▶ Trust God and not your own limited understanding (Proverbs 3:5–6). ▶▶ Be still and let God be God (Psalm 46:10a). ▶▶ Do not to be distressed about anything, but instead submit yourself and your problems to God, who promises to love and take care of you (Philippians 4:6). In other words, Christians are asked to accept God’s sovereignty in the circumstances of their lives on the basis of his expressed character, wisdom, and loving intentions. Several other foundational issues in the Christian faith are sin, repentance, and forgiveness. According to Christianity, we are all born with a sinful nature because of the actions of Adam and Eve. This sinful nature separates us from God and leads to death, necessitating a savior for humankind. Christians believe that this savior is Jesus Christ, the son of God, who lived as a man on earth without sin. His sacrificial death on the cross was the payment or

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atonement for all humankind’s sin. As a result of his death and resurrection, we can now be forgiven, made righteous, and reconciled to a holy God. The Bible commands believers to regularly confess their sins to God, who is “faithful and just to forgive us our sins” (1 John 1:9) and who puts our sin as “far as the east is from the west” (Psalm 103:12). God’s forgiveness allows individuals to exchange their unrighteousness for Christ’s righteousness (2 Corinthians 5:21). Christians are also to repent of their wrongdoing to the people they have hurt and ask for their forgiveness (James 5:16). Similarly, Christians are instructed to love their enemies (Matthew 5:43–45), withhold judgment (Luke 6:37), show mercy, and forgive others as God has forgiven them (Mark 11:25). They are to live in peace with one another and to leave vengeance and justice up to God (Romans 12:18–19).

= “To be a Christian means to forgive the inexcusable, because God has forgiven the inexcusable in you.”17 “Forgive us our debts, as we also have forgiven our debtors” —Matthew 6:12

Acceptance and Forgiveness Skill-­Building Activities The “Letting Go and Letting God” tool employs acceptance and forgiveness from a Christian perspective. Similar to work addressing spiritual struggles, sensitivity to timing for the use of this tool is essential. We risk adding to our clients’ pain if we introduce acceptance or forgiveness prematurely as potential therapeutic strategies.

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Clients first need the opportunity to better understand what they are feeling and why, and they need to do this processing within the safety of a strong therapeutic relationship. They also need to receive validation from us for their feelings. Once these things have occurred, clients may benefit from the following activities that facilitate acceptance, forgiveness, or both.

Acceptance through Active Spiritual Surrender One way to facilitate the process of letting go and letting God through acceptance is called active spiritual surrender. It could also be called active spiritual trust because it entails entrusting situations to God’s care. In this exercise, clients assess which things in their lives are beyond their control and how actively releasing these things to God might help reduce their depressive symptoms. As we discussed earlier, acceptance through active spiritual surrender often has a paradoxical effect in that many clients feel a greater sense of control and peace afterward. That said, the motivation to engage in active spiritual surrender is not to gain more control. Rather, it is a recognition that surrender is of greater spiritual value than is (attempting to) maintain control. This recognition has been called going from “playing God” to “seeking God.”18 Guidelines for active spiritual surrender are as follows: 1. The client begins by drawing a line down the middle of a piece of paper. On one side, she lists the things in her life that she is able to control. These might include how she spends her free time, whom she chooses as friends, and where she goes to church. On the other side, she lists all the things she cannot control. On this list she might include things such as being laid off, getting cancer, and losing her husband. 2. When she is finished with her list, we can ask how she typically copes with things that are under her control versus not under her control and whether she has found these strategies effective. 3. Next we introduce the concept of acceptance and discuss how we increase our suffering by trying to control things that are uncontrollable, yet we often find ourselves doing just that. Usually this

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discussion involves exploring strong emotions, such as fear, anger, guilt, and resentment. The well-­known Serenity Prayer by Reinhold Niebuhr is a useful reference here.19 4. We can then ask what her Christian beliefs, teachings, and worldview have to say about people’s ability to control how their lives unfold, as well as what they say about the concept of acceptance. This may involve a discussion about trust, God’s character, power, and sovereignty, biblical instructions not to worry, and other such religious concepts related to surrender. 5. Following this, we introduce the idea of active spiritual surrender and differentiate it from defeat, giving up, being passive, not caring, and agreeing with one’s current state of affairs. We note how acceptance of one’s reality by relinquishing control to God can reduce suffering. 6. Next, we explore any religious motivations the client may personally have to engage in active spiritual surrender, and inquire if this approach is something she would like to try. If so, we can elicit what it would mean for her to surrender to God each of the uncontrollable things in her life. If she would like to engage in active spiritual surrender, we should determine if she would like to do this with us in session or at home on her own. She might surrender the issues in prayer, or write a letter to God surrendering the issues, or engage in some sort of symbolic action to mark the surrender, such as writing the issues on slips of paper and leaving them on the altar at church.

Clinical Application Of course, in clinical practice, things are almost never as neat and tidy as simply following seven steps. Below we see how the therapist needed to go off script, so to speak, in exploring how acceptance and active surrender might be helpful strategies for Hee Jung.

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Therapist: It sounds like one of the most challenging parts of this whole experience is the belief that you were in control of the outcome of the pregnancy. Hee Jung: A mother has everything to do with how well a pregnancy goes. The baby is growing in her body, after all! Therapist: I agree that the mother, more than anyone else, has a large influence on how the baby develops. The part I challenge you on is the belief that the mother has all the control. Lots of women do everything their doctors tell them to do and yet their babies are born with health problems and birth defects. And some babies, like your precious Jia, die in the womb. The pain is just so excruciating that sometimes it’s easier for us to blame ourselves than to have no explanation at all for what happened. I just wonder if believing you were at fault might be easier than accepting what your doctor said—that the miscarriage wasn’t a result of you or your stress at work. Hee Jung: [long sigh] I don’t know, maybe. I find it hard to accept that there is no explanation for something like this. Therapist: It’s very hard for us to accept that there are things in our lives—very important things—that we can’t control. Not accepting something or finding blame are some of the ways we try to maintain a sense of control over our world. Unfortunately, when we try to control things that we have no control over, we end up increasing our suffering. Accepting something doesn’t mean we agree with or like what happened. Acceptance simply means being willing to be open to our present reality without denying it or trying to change it. To let what is be just as it is. Hee Jung: Living in a reality without my baby sounds equally difficult. Both ways involve suffering. Therapist: Both involve pain, that’s for sure. But one way allows you to begin to move forward in life and the other way keeps

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you stuck. The way that keeps you stuck, the not accepting, is causing suffering on top of an already painful situation. Hee Jung: It feels like I’ve been fighting a losing battle for the last two years. Therapist: That’s a good metaphor. Who exactly have you been fighting? Hee Jung: I know I’ve been fighting myself, and God. Lately I’ve also been fighting my husband. It’s exhausting, but somehow it feels like if I accept her death, and accept that I did my best, that I’m giving up. Like I’d be passively accepting defeat, and I’m not a quitter. Therapist: No, you certainly are not a quitter. In a sense you would be giving up, but that’s different from being defeated or being passive. You would be ending the battle by actively choosing to give up the dream and hope you had of spending a lifetime with your daughter. You’d be choosing to give up your way of understanding how the world works, and of how God works. You’d be surrendering your attempts to make things go how you think they should go. Acceptance and surrender are never passive and they’re not easy, but they are very effective in ending the battle that causes so much suffering. Hee Jung: I can see how accepting that I did my best would bring a sense of peace and relief. But I can’t just pretend that I’m not angry at God for not keeping his promises. He didn’t do his best. Notice that in this dialogue about active surrender, the therapist did not suggest acceptance in the context of surrendering to God. Hee Jung still needs to process her feelings of anger and betrayal toward God. Surrendering to God would not feel safe right now. She needs another strategy to help her in this process of letting go and ultimately letting God.

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Repentance and Forgiveness A second way clients can “let go and let God” is through seeking and granting forgiveness. For many clients, forgiveness can be a powerful antidote to guilt, anger, resentment, depression, and spiritual struggles. Clients who are ready and desiring to explore forgiveness as a strategy for improving their mood can be guided through a series of steps for extending forgiveness toward themselves, others, or God. These steps can also be used for seeking forgiveness. Of all the forgiveness interventions available, Worthington’s REACH model20 and Enright’s process model21 have the greatest empirical support and fit within a CBT model. These models include defining forgiveness, processing the feelings regarding the offense, making a decision to forgive, working to develop empathy for the offender, and holding onto the decision to forgive. Steps from these forgiveness intervention models have been modified below for the integration of Christian beliefs, motivations, and practices. Of note, for hurts that are long-­standing and severe, and that involve more than one transgression or transgressor, more than one session should be devoted to working through these steps. Steps for seeking and granting forgiveness are as follows: 1. Once a client has had the chance to process the perceived wrongdoing and accompanying negative emotions (which can take many sessions), we can begin a conversation about repentance and forgiveness. These tools can be described as key in the Christian faith and the psychological literature for dealing with negative feelings that result from transgressions and injustices, either committed by us or against us. Clients should not feel pressured to engage in forgiveness. This is simply an option and one that a client might not want or be ready to use at this point in time. 2. Forgiveness needs to be introduced with care and good clinical judgment so that the client doesn’t feel that we are trivializing her pain. One sensitive way to begin this conversation is to ask how she defines forgiveness and repentance. This is a good time to listen for the ways her Christian worldview informs her definitions—and to ask explicitly if that worldview is not offered.

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3. During this conversation, we are attuned to any misgivings or misinterpretations she may have about forgiveness. Her definitions guide how we explain the critical aspects of forgiveness from a psychological perspective: ▶▶ Granting forgiveness does not mean the action was right or justified. ▶▶ Forgiveness is not the same as reconciliation. ▶▶ Forgiveness is a choice we exercise with our wills. ▶▶ When we forgive, our emotions might not change right away. 4. We can then ask for the client’s thoughts about these general criteria and whether she agrees with them. 5. As she is describing her definition of forgiveness, we are also listening to see if and how her understanding of forgiveness is congruent with that of general Christian theology. Remember that various divisions and denominations within Christianity have some different teachings about forgiveness. It is not possible to review all of those differences here, but a few major similarities are as follows: ▶▶ God wants us to forgive others as he forgives us. ▶▶ We are to leave vengeance up to God. ▶▶ God is a God of both justice and mercy. ▶▶ God is the one who completes the work of forgiveness in our hearts. 6. Concerns or discrepancies between our client’s definition of forgiveness and that of Christian theology can be explored together. For example, she may be resistant to the idea of forgiveness because she thinks it is incompatible with justice. It may be helpful for her to consider the fact that scriptures portray God as being both just and merciful, and that forgiving someone is acknowledging that God is the ultimate judge. The purpose of this discussion is not to debate Christian theology. Rather, we are providing an opportunity for our clients to consider other ways of thinking, including the opportunity to challenge spiritual beliefs that may be helping to maintain their depression. 7. Next, we can ask our client why people are motivated to forgive.

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In this discussion, we can review the impact unforgiveness can have on our emotional, spiritual, and physical health. 8. If she did not mention her faith, we can ask whether her Christian beliefs are a source of motivation for her in granting and seeking forgiveness. Christianity-­based motives might include the scriptural mandate to forgive, being forgiven in the past by God and others, a desire to honor God or give a gift of forgiveness, loving God by loving others, the mandate to live in peace with others, and praying for our enemies. 9. Now we are ready to ask the client specific questions about her desire to forgive. ▶▶ Do you think granting or seeking forgiveness would help you deal with [insert her specific situation or negative emotions]? ▶▶ Who would you like to forgive (others, self, God)? Note that although God cannot sin, we can perceive God as having done something to hurt us. Forgiving God is really letting go of our anger and resentment toward him. ▶▶ Would you like to ask for forgiveness for anything? Who would you like to ask (God, others, self)? 10. If there is more than one perceived offender or offenses, the client can be invited to make a list of the people she wants to forgive. If applicable, she can also list the wrongs for which she would like to seek forgiveness. This exercise can be done in session or at home. Note that clients may need to forgive themselves or God, as well as other people. 11. A critical step in the process of forgiveness is developing empathy and compassion for the perceived offender. Completing an ABCD(R)E thought log may help the client to see the situation better from the other person’s point of view. 12. If the client wants to, she can be given the opportunity to offer forgiveness in session either through prayer, a written letter, or an empty chair role-­play in which she verbalizes forgiveness to the other person. If she chooses to express forgiveness through prayer, she may want to pray silently or aloud. If she chooses to forgive in

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session, process what this activity was like after she is finished. A sample prayer is provided below in case clients want guidance for either offering or asking for forgiveness. Clients should be encouraged to use wording that is most comfortable and genuine for them. Again, clients should not feel pressured to engage in prayer or to offer forgiveness if this is not something they desire to do. 13. If the client prefers to offer or seek forgiveness at home, establish the day and time she will do this. As with all home practice assignments, a specific plan makes it more likely that the client will complete the exercise. She may also want to pray for the offender, as instructed in scripture. This practice may continue to soften her heart and cause her emotions to line up with her decision to forgive. A prayer such as one of the following can be said for each item on the client’s forgiveness list.22 Emphasize that addressing each issue separately is more meaningful than saying one general prayer for all offenses listed. A sample prayer granting forgiveness is as follows: Dear God, You ask that we forgive others as you have forgiven us, so today I choose to forgive ___ [the person] for ___ [the action]. What this person did hurt me, but I am choosing to no longer hold this against him/her and to cancel the debt he/she owes me. I ask that you would also forgive him/her for this action. Please forgive me for the bitterness and resentment (anger, hatred, etc.) that I have stored in my heart because of this offense. I give you all my negative feelings and ask that you would cause my emotions to line up with my decision to forgive ___ [the person]. I also choose to forgive myself for holding onto this unforgiveness. Thank you for forgiving me and making me righteous in your sight. Please heal my heart of this hurt and fill me with your truth. Amen.

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A sample prayer seeking forgiveness is as follows: Dear God, You say that if we confess our sins to you that you are faithful and just and will forgive us of our sins and cleanse us from all unrighteousness. I confess that I ___ [the wrongdoing]. This was wrong and hurtful, and I am truly sorry. Please forgive me for ___ [the wrongdoing]. I commit to changing my ways and ask for your help not to do this again. Thank you for your mercy and for putting my sin as far away as the east is from the west. Amen.

Clinical Application We conclude by returning to the case about Hee Jung and see how the therapist introduces forgiveness as a way to reduce her negative feelings—another way of letting go and letting God. Therapist: Tell me more about how you’re feeling about God’s role in the miscarriage. Hee Jung: I haven’t admitted this to anyone at my church because it’s not very Christian of me, but I’m angry at God. He let me down when I needed him the most. He makes all these promises in the Bible about helping us in our time of trouble, how if we just believe then nothing will be impossible, that he will protect us and heal us. It’s not like I didn’t ask or didn’t believe. I upheld my end of the bargain; he did not. Therapist: Let me begin by saying that I don’t think there is anything un-­Christian about feeling angry at God. There were lots of devout people in the Bible and since then who have expressed anger toward God. If God could handle their anger toward him, I’m willing to bet he can handle yours, too. But I can see how painful this situation is for you. It must feel like a betrayal, God not keeping this bargain. Hee Jung: That’s exactly what it is, a betrayal, a divine betrayal.

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Therapist: This experience has turned things upside down for you. I know scripture has been very important to you in your life. I also know your experience has not lined up with how you have understood the scriptures. Has that changed how you view the Bible? Hee Jung: I still believe the Bible is true, if that’s what you mean. If it’s not true, then everything I built my life on is false, everything falls apart. I guess I don’t just believe the Bible is true, but I need it to be true. Therapist: I get it. Your whole worldview is built upon your faith, and your faith comes from what the scriptures say about God. I respect that, and hear me when I say I’m not suggesting that you question whether the Bible is true. What I’m gently inviting you to consider is that perhaps your interpretation of some of the scriptures may not accurately reflect the truth of the scriptures. For instance, could it be possible that God does care for and protect us and at the same time also chooses for some of us to live long lives and some of us to live short lives? Does one have to negate the other? Hee Jung: I suppose not. We’re all going to die sometime. That doesn’t mean God doesn’t love or protect us. It’s just that . . . I didn’t want my daughter to die before I had a chance to know her. [cries] Therapist: Of course you didn’t. No one wanted it to turn out like this. Hee Jung: I can’t go on living like this, sad and angry all the time. How do I get rid of all these feelings? I feel like my daughter isn’t the only one who died that day. Therapist: We talked a little about acceptance, but I think another major part of your pain has to do with the betrayal you feel by God and not forgiving yourself for your perceived role in the miscarriage. Forgiveness can be a very effective way

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of dealing with the kind of painful feelings you’re experiencing. Both acceptance and forgiveness are ways of letting go and letting God be God, even though you don’t understand all of what he allows. They could be helpful tools for ending the battle you’ve been fighting for the last two years. Would you like to talk about how forgiveness might be helpful? Hee Jung: I’d be willing to discuss it. Therapist: How would you define forgiveness? Hee Jung: It’s letting go, like you said. Letting go of resentment and anger and trying to get revenge. But I don’t think I can do that because I will never see the miscarriage as being the right thing to have happened. Therapist: Forgiveness is letting go, but it doesn’t mean you agree with what happened or that what happened was right. If you forgave, what you’d be doing is accepting that the miscarriage happened and choosing not to hold it against yourself or God anymore. You’d be choosing to trust God’s sovereignty and his love, accepting that one doesn’t negate the other, even though you don’t understand it. I’m curious if there are teachings in Christianity about forgiveness that we might consider. Hee Jung: Jesus says we’re supposed to forgive others because God forgave us. We’re supposed to forgive our enemies. I think it says we’re supposed to pray for them, too. Therapist: What do you think about these teachings? Hee Jung: I think they’re not easy to follow! Sometimes it helps to think about how Jesus forgave me; that’s the gospel message in a nutshell. We’re supposed to follow in his footsteps, and that means loving and forgiving other people. Therapist: Including yourself? Hee Jung: Yeah, I guess that would include myself.

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Therapist: And God? Hee Jung: How can we forgive God if God can’t sin? Therapist: In this case, I imagine it would look like letting go of the perceived wrong and choosing to release the anger and resentment you’ve been holding onto. Hee Jung: It would help if I could see God as still upholding his word. That maybe he is caring for Jia in heaven, protecting her and loving her there. If that’s true, then he is keeping his part of the bargain, just not how I hoped he would. Therapist: How does that belief make you feel inside? Hee Jung: Better. Still sad, but less angry. Therapist: Would you like to forgive yourself and God, to end the battle you spoke about earlier? Hee Jung: I’d like to try. Holding onto all these feelings certainly isn’t helping. I keep thinking of that verse that says, “Be still and know that I am God.” I have a hard time being still and trusting that God knows best. If I could learn how to do that, I could relax more, trust more. Maybe I could even get to the place of wanting to try to get pregnant again. Hee Jung added her husband to the list of people she wanted to forgive and decided she would like to say prayers of forgiveness in the privacy of her home. The following week, Hee Jung reported feeling like a heaviness had left her body when she prayed. She still felt sad about her loss, but she didn’t feel the same anger she had been holding onto for the last few years. Note that this was the fifth session, not the first or second, in Hee Jung’s treatment. Acceptance and forgiveness are tools that need time and sensitivity to be used appropriately and effectively. Only after Hee Jung was able to express how she was feeling—feelings she wasn’t comfortable sharing with her Christian friends—was she

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ready to work toward accepting her daughter’s death and to forgive both herself and God for their perceived role in the miscarriage. Letting go and letting God was a new way of operating for Hee Jung and one that has the potential to bring freedom and healing into many domains of her life.

= Tool Summary Clients can use the Letting Go and Letting God tool through the following activities: ▶▶ Acceptance through active spiritual surrender ▶▶ Repentance and forgiveness of self, others, and God

Chap ter 9

Saying Thanks Gratitude

Thank [God] in everything [no matter what the circumstances may be, be thankful and give thanks], for this is the will of God for you [who are] in Christ Jesus [the Revealer and Mediator of that will]. —1 Thessalonians 5:18 AMP

Meet Sally

S

ally is a forty-­two-­year-­old Christian single mother who was laid off three months ago when her company was downsized. Sally has two children under the age of ten and rarely receives any of the court-­mandated child support from her ex-­husband. She has only a few weeks of severance pay left. Although Sally has applied for jobs daily, she has not been offered any interviews. Her faith is important to her, but her current difficulties are causing her to question whether God cares for her and her children. She sought out therapy after finding herself crying with little provocation, yelling at her children (something she had rarely done in the past), having trouble falling and staying asleep, and losing her desire to spend time with friends. The following is an excerpt from her sixth session of CCBT. Sally: I used to be such a happy, positive person, but lately all I seem to do is complain. I’m getting on my own nerves. Therapist: I wonder if there is something else you might try doing when you find yourself complaining.

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Sally: When I used to have a pity party as a kid, my mother would tell me to think about how much better off I was than most people in the world. Therapist: Did it help to make this comparison? Sally: Maybe then, but that trick doesn’t work so well anymore. What I’m going through now is nothing compared to my difficulties in childhood. In fact, I’ve become the person to whom others compare to cheer themselves up! Sally certainly has a lot she could complain about, and she’s not incorrect when she says others might be grateful not to be in her position. But complaining will only make her mood worse. What Sally needs is a compelling motivation to stop complaining and a substitute behavior that will help shift her negative mood and focus off of herself and her problems. In this chapter, we explore how expressing gratitude from a faith-­based perspective can be an effective cognitive reframing and positive behavioral tool for clients like Sally.

Why We Say Thanks Culturally, we are taught that expressing gratitude is good manners. In fact, “thank you” is one of the first phrases we learn to say as children. In general, we express gratitude because it’s polite and it’s the right thing to do, and we feel grateful when things are going well, or aren’t as bad as they could be. Gratitude fits well within a CBT treatment approach for depression. In contrast to the negative focus on self, others, and the future when depressed,1 gratitude shifts our clients’ focus and actions to that which is positive and satisfying in their lives. Thus, choosing to be grateful exemplifies the very essence of CBT: changing negative interpretations and behaviors to elicit emotions incongruent with depression.

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Scientific Support for Gratitude The research on gratitude and well-­being is growing. The data show that grateful people tend to be happy, optimistic, flexible, creative, and hopeful. They also report having more energy, sleeping better, being more satisfied with life, having better relationships, and being better able to forgive others compared to those who are less grateful. Given these findings, it is not surprising to learn that grateful people are also less likely to be depressed, anxious, angry, and self-­focused.2 Being grateful has also proven to be a helpful coping strategy for dealing with negative life events.3 Given the benefits of being grateful, the question follows whether we can elicit this state so that people can experience gratitude and its benefits more often and to a greater degree. The answer is that we can. Researchers have found that we can do things to feel more grateful, and when we do, we reap the benefits of gratitude. To elicit a state of gratitude, social scientists have developed “gratitude interventions”—activities to work our gratitude muscles, so to speak. Individuals who complete these gratitude activities in an experimental setting or as part of psychotherapy report greater happiness and a reduction in depressive symptoms.4 Some research has also shown that religious people are more likely to express gratitude than people without religious beliefs.5 This may be because gratitude is a virtue that is highly valued and encouraged within the major world religions, including Christianity. Believers are taught to count their blessings, be grateful regardless of difficult life circumstances, and offer prayers of thanksgiving to God. As such, a client with a Christian belief system has a potentially powerful source of motivation and encouragement for cultivating a grateful attitude and grateful behaviors. There also seem to be rewards for expressing gratitude to God. One study found that saying prayers of thanksgiving was associated with fewer depressive symptoms among cancer patients.6 Another study reported that for those who are highly religiously committed

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(defined as degree of belief in God, importance of religion, and integration of religion in life), expressing gratitude toward God— called religious gratitude—results in even greater well-­being than expressing nonreligious gratitude.7 In our clinical trial on religious CBT versus conventional CBT, religious clients who were taught the gratitude exercises I describe below became more grateful, 8 and a higher level of gratefulness predicted greater improvement of major depression. We also found that the more religious a client was before treatment began, the more grateful they reported being after treatment.9

Christianity and Gratitude In Christianity, expressing gratitude isn’t just good manners, it’s a sacred instruction repeated throughout the Old and New Testaments. As such, gratitude is morally and spiritually mandated. When counseling Christian clients, at least two important features of these sacred gratitude instructions are important to know. First, Christians express their gratitude not just to people but also to God. Scriptures, such as the following verse in the book of James, assert that God is the source of every good thing that happens in the life of a believer: “Every good and perfect gift is from above, coming down from the Father of the heavenly lights” (James 1:17a). Whether a special gift from a loved one, a raise at work, or the absence of the usual heavy traffic on the morning commute, each event is seen as ultimately coming from God. Someone who is not a Christian may encounter the unexplained lack of usual traffic and feel happy and appreciative, but there isn’t anyone specific to thank for this occurrence. A Christian, on the other hand, will likely thank God for providing the easy commute. As researchers have noted,10 Christians thus have a wider range of things for which to express gratitude, as well as another important being to thank. The second way gratitude differs for Christians is that they are instructed to give thanks for everything, not just positive things. The apostle Paul told the early church in Thessalonica to “give thanks in

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everything [no matter what the circumstances may be]; for this is the will of God in Christ Jesus for you” (1 Thessalonians 5:18). Notice Paul wasn’t instructing the early Christians to feel grateful; he was admonishing them to express their gratefulness. Expressing gratitude when negative and hurtful events happen is not typical human nature! This scripture passage does not mean we should suggest that a client feel happy when bad things happen. Clearly, such an attitude would be harmful to the client and to the therapeutic relationship. It would also be theologically incorrect. Theologians seem to agree that Paul did not admonish believers to thank God for everything, but rather in everything, including in negative circumstances. For example, Christians can, in the midst of a negative event, thank God for who he is, his role in their lives, how he will bring them through the situation, and how even this event will be used for their good (Romans 8:28). I had a client who, after reading this verse exclaimed, “To think I’ve been a one-­way thanker all these years!” To her, being a “two-­way thanker” meant giving thanks to God in the desirable and undesirable circumstances of life.

Religiously Integrated Gratitude Skill-­Building Activities To generate buy-­in from our clients when introducing this tool, it is helpful to provide a rationale for why gratitude can be an effective strategy for reducing depression. Part of this rationale can be the empirical associations between cultivating gratitude and better mental health, as we saw in the scientific literature reviewed earlier. Because gratitude can feel incongruent with clients’ current feelings of pain and suffering (which is the point!), we run the risk of coming across as insensitive and invalidating. To try to avoid this possibility, explain to clients that they don’t need to rid themselves of feelings of depression to be grateful. Rather, the positive feelings generated by expressing gratitude can help to distract from and overcome the feelings of depression.

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In religiously integrated CBT, we support our clients not just in developing general gratitude but also in developing religious gratitude—thankfulness to God. In this approach, together we explore the client’s religious motivations and values for being thankful. For example, we might discuss in what ways gratitude is an important part of our client’s Christian faith and how it might include being grateful to God and the things, people, and experiences God has provided. One way to introduce religious gratitude to clients with depression may look something like the following: Are you aware of any verses or teachings in the Bible that talk about being thankful and giving praise to God?

[Depending on how the client responds, we might offer the following.] Both the Old and New Testaments have a lot to say about gratitude. Jesus and the disciples gave thanks on many occasions. And King David was constantly thanking God, as recorded in the Psalms, saying things like, “Let them give thanks to the Lord for his unfailing love and his wonderful deeds for mankind” (Psalm 107:8). The apostle Paul said something interesting to the Christians in Thessalonica about gratitude. He said, “Thank God in everything, no matter what the circumstances may be; be thankful and give thanks, for this is the will of God for you who are in Christ Jesus” (1 Thessalonians 5:18). This isn’t how we usually think about gratitude, is it? We are thankful when things go well, but this verse seems to say that no matter what we feel or what difficult situation we’re facing in life, God wants us to be thankful all the time. Maybe that’s why the Psalms say we are to give a “sacrifice of thanksgiving” (Psalm 116:17 AMP). What are your thoughts? Why do you think being thankful is God’s will no matter what we are going through?

Next we’ll look at three tools from the research on gratitude and CBT that can be modified for use with Christian clients.

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Counting Your Blessings Activity: The Gratitude List The first gratitude activity, called “Counting Your Blessings,” is a slightly modified version of the classic positive psychology gratitude list exercise. As with the classic activity, the client is given a pen and paper and asked to spend five to ten minutes generating a comprehensive list of all the things for which he is grateful. This list might include people, past and present experiences and opportunities, living conditions, material possessions, and nature. Within the context of CCBT, clients are asked to include on their list things that relate to their Christian faith. We can frame the instructions within a religious context to explicitly activate clients’ own religious values and motivations. For instance, we might say, “As you are making your list, you might also think about all the things God has given you for which you are grateful.” After creating as comprehensive a list as he can, we ask the client to rate his level of gratefulness for each item on the list. We can use a scale from 1 to 10, in which 1 is “not very grateful” and 10 is “very grateful.” After our client has rated each item, we review the list with him, paying particular attention to the items he ranked most highly. Questions we might ask to generate discussion include the following: ▶▶ Could you share what it is about X that makes you feel grateful? ▶▶ What about X moves you when you think about it? ▶▶ How does X tie in with your faith or your view of God? We can encourage the client to add to his gratitude list throughout the week. For instance, we might instruct him to add one new thing to his list each night before going to bed. Or we might instruct him to think of one thing for which he is grateful before he lets his feet touch the floor in the morning. He might also try expressing gratitude with other people on a regular basis. For example, each person says at least one thing they are grateful for during a meal or on the car ride home from school. This activity could be modified

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such that each person states one of their perceived strengths, as well as a perceived strength of another family member. To have maximal impact, the items should be different each time. In addition, if he keeps his gratitude list in a file or journal, he will have an enduring resource to access should he find himself struggling with depressive thoughts in the future. These reflective gratitude activities challenge our clients to consciously think about their day and their life from a positive and faith-­based perspective. It also broadens their awareness of things in their lives that are positive rather than negative. In subsequent therapy sessions, we can review the expanded gratitude list with a particular focus on what our client noticed as he redirected his attention to the things for which he is grateful. When clients express that the activity had a positive effect on their mood, we can ask them to reflect on why they think this effect occurred. The idea is to have our clients make connections between being grateful and any changes in their mood and behavior. We might explore with our clients questions such as these: ▶▶ Do you like the kind of person you are when you practice gratitude? ▶▶ What does it mean to be a grateful person? ▶▶ What effect, if any, did it have on your relationship or feelings of closeness to God? Exploring the religious meaning of and motivations for feeling grateful is important, as it helps to ground the exercise in the client’s value system and provides another personally relevant reason for continuing to practice gratitude.

Practicing Cognitive Restructuring from a Gratitude Framework The gratitude list can serve as an effective resource for helping clients challenge and change unhelpful, negative thinking. At this point in treatment, clients will be familiar with the ABCD(R)E approach to challenging their thoughts. We can instruct the client to work through the ABCD(R)E approach for a recent negative thought or expectation. This time, when he works through step D, “Disputing

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negative thoughts,” he can use his gratitude list as one source of evidence. In other words, he can review his gratitude list to see if any of the items on the list, or his understanding of God as the source of these items, provides material to help him refute his negative belief. For example, a belief such as “nothing is going well in my life” can be challenged by the very fact that he had things to put on his gratitude list. When we revisit the case about Sally from the beginning of the chapter, we will see how the therapist used cognitive restructuring from a gratitude framework.

Gratitude Behavior: Prayers of Thanksgiving and the Gratitude Letter Gratitude is not just an attitude or feeling state that can be cultivated, it is also a behavior. Like other types of behavior, grateful behavior can lead to a feeling state incongruent with depression. Gratitude can be expressed in many ways. One way for Christian clients to express gratitude is by praying prayers of thanksgiving to God. For clients who are depressed and lethargic, praying is a good beginning-­level activity that does not require a change in setting or a great deal of physical exertion. We can suggest that they spend part of their daily prayer time praying though their gratitude list, thanking God specifically for each item. Prayers of thanksgiving can also be said when clients notice feelings of anxiety. A relevant scripture reference for this can be found in the book of Philippians: “Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God” (Philippians 4:6). The gratitude letter, one of the classic activities used in gratitude research, is another grateful behavior our clients can try.11 This activity is more involved than the gratitude list. As such, when introducing this activity, it can be helpful to explore how the instructions to express thanksgiving found in scripture might provide a source of motivation for doing so. For this exercise, we ask our client to identify a person for whom she feels especially grateful. It works best if the person she chooses is living so that she can experience what it is

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like to both deliver her message of gratitude and have the other person receive this message. Although this exercise may be a good one to repeat with God as the recipient, being able to witness the impact of the client’s expression of gratitude is important, and as such, at least one letter should be written to someone other than God.12 Here is one way we can introduce the gratitude letter activity to our clients: Gratitude is more than just a feeling. It can also be a behavior. For example, have you ever received a thank-­you card in the mail or had someone elaborate on why they appreciate you or something you did? How did that feel? One way to love others is to be intentional about creating that good feeling in them. We can do that by telling them all the reasons why we appreciate them being in our lives. Interestingly, when we help to create that positive feeling in others, we end up creating it within ourselves, too. Can you think of anyone in your life who did something kind for you that touched you deeply? Someone whom you would like to thank more fully?

If the client has trouble identifying someone, we can suggest that he consider people such as family members, teachers, church members, friends, coaches, and so on. Once he selects a specific person, we can engage him in a discussion about what precisely this person did for him that was so meaningful. This discussion will become the content of his gratitude letter. We then encourage the client to identify concrete behaviors and to be as specific as possible. For example, saying, “You were kind to me,” is not as meaningful as, “You believed in my ability to attend college when no one else did. You repeatedly sacrificed your time to help me with my schoolwork after class to help me improve my grades.” After identifying specific, concrete behaviors the person did for him, he can describe the meaning of those actions to him by answering questions such as the following: ▶▶ How did that action make me feel?

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▶▶ How did it impact my life? ▶▶ What did it teach me? ▶▶ How have I changed as a result?

He can also describe the qualities and traits he admires and appreciates in this person, such as courage, strength, kindness, or generosity. Again, it helps to be specific and to provide an illustration in the letter of a time when the client noticed that character trait in action. After the letter is written, the next step is to deliver the letter to the recipient. Ideally, delivery is done in person so that the client can have the entire sensory experience of witnessing someone receive the words of gratitude. However, this meeting is not always possible given geography or our clients’ ability or desire to do so. In these cases, the letter can be read over the telephone or delivered by mail. To ensure that this step is completed, we should ask clients to pick the time, place, and means of expressing their gratitude letter before concluding the session. To ensure the full clinical impact of the exercise, we need to follow up with clients in a subsequent session about the delivery experience. We might ask questions such as these: ▶▶ What impact did it have on the recipient? On you? ▶▶ What was it like to express gratitude despite feeling depressed? ▶▶ Did this experience affect how you view the instructions in scripture to give thanks in all things? If this is a behavior our clients would like to continue, we can work together to plan other expressions of gratitude, including being more intentional about expressing gratitude to others throughout their day. Again, we want to remember to tie these expressions of gratitude into their religious motivations and values.

Clinical Application Let’s return to the case about Sally, who as we saw in the beginning of the chapter needed a compelling motivation to stop complaining

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and a substitute behavior to help shift her mood and her focus to something positive. In the excerpt below, we see what it looks like to use cognitive restructuring from a gratitude framework. Note that Sally was already proficient at using the ABCD(R)E approach to challenging and changing her negative and unhelpful thinking. At this point in the session, Sally has just finished completing her gratitude list. Therapist: It looks like you’ve come up with a long list of things you are grateful for. Sally: Yes, I guess it’s easy to forget that there are a number of good things going on in my life even though things are so uncertain financially. Therapist: When we’re dealing with challenging issues it can be hard to remember that there are also positive things in our lives. What do you notice inside when you read through your list? Sally: I notice I’m feeling a little lighter. I mean, I’m still upset about losing my job and anxious about the future, but it’s a little less intense. Therapist: So, shifting your focus to what is going well in your life helps to make the sad and anxious feelings less intense. Maybe this is one of the reasons scripture says to thank God in all things, including negative circumstances. Sally: I hadn’t thought of that. I’m not grateful I’m going through all this, but being grateful in the midst of it does seem to bring a little relief. Therapist: I know one of the things you’ve struggled with since being laid off is the thought that maybe God doesn’t care about you and your children. I wonder if we can challenge that belief some by using the ABCD(R)E method and the gratitude list you just created.

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[Sally completes steps A, B, and C of the thought log.] Therapist: How much do you believe the thought, “God must not care about me and my children if he let me be laid off,” on a scale of 1 to 10? Sally: About an 8. Therapist: Okay, let’s proceed to step D and see what evidence we can gather to help dispute this belief. What evidence can you draw from your gratitude list? Sally: Well, there are still a lot of good things in my life, and our basic needs are being met. I mean we haven’t gone a day without food or electricity or a place to live. My mother helped out with the unexpected car expense, and that was a real blessing. Therapist: So you’re noticing that despite not having a job right now, your basic needs, as well as an unexpected need, are being met. Sally: Yes, and I also notice that I’ve never been without a job for long. I’ve had a number of good jobs in my life, and even though I don’t receive child support most months, I’ve still been able to provide for my children. Therapist: These are all really good insights. How can you use this information to help dispute the belief that God doesn’t care for you and your children because he allowed you to be laid off? Sally: Well, it’s clear from looking at this list that God has always provided for us even when it looked like we should be in serious trouble. He didn’t stop caring for me when I lost my marriage, so why should I think he stopped caring for me when I lost my job? I can see that he has continued to provide, even if it’s not how I was hoping things would be right now. Therapist: It sounds like seeing God’s history of providing for

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you and your children is helping you feel more confident that he will continue to care for you all now. Sally: Yes, that’s right. Therapist: How much do you believe the thought, “God doesn’t care about me and my children because he allowed me to lose my job”? Sally: Hmm, not very much now. Maybe 1 out of 10. Therapist: Let’s complete step E. What is a more helpful and accurate belief based on the evidence you have? Sally: That God has provided for us in the past and there is no reason to believe he has stopped caring about us now. Therapist: How does that new thought make you feel? Sally: Relieved. Hopeful. I don’t feel as sad. Therapist: What would help you to remember this new way of thinking? Sally: Maybe I could post my gratitude list on my mirror. That way I can start every day thinking about how God has cared about us in the past and how he will continue to care for us. Therapist: I think that’s an excellent idea. Maybe you could even whisper a quick prayer of thanksgiving to God in the morning for the items on your list. Sally: I like that. I think it will help me feel more connected to God. The next time the therapist meets with Sally, she can inquire about whether Sally posted her gratitude list on her mirror, what impact this action had on her thoughts and emotions, and her current belief in the accuracy of her old, unhelpful thought that God didn’t care about her or her children. Reviewing the effects Sally

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experienced by expressing gratitude will help to solidify her new skill, making her more likely to continue to use it. This sample dialogue illustrates how gratitude from a religious perspective can be an effective tool for combating depression. Gratitude provided Sally with a compelling reason to stop complaining and to instead express thanksgiving to God for the positive things in her life, past and present. Not only did using gratitude as a tool help shift her focus, it also helped her to resolve her depression-­ maintaining belief that God no longer cared about her family. The biblical instructions to give thanks to God in all things, including in negative circumstances, gives Christian clients like Sally a different lens from which to view their lives, as well as a set of positive behaviors to engage in that are incompatible with depression.

= Tool Summary Clients can employ the Saying Thanks tool by completing the following activities: ▶▶ Counting their blessings by writing a gratitude list ▶▶ Practicing cognitive restructuring using gratitude as

a new mental framework ▶▶ Praying prayers of thanksgiving ▶▶ Writing and delivering a gratitude letter

Chap ter 10

Giving Back Service “And the King will reply to them, ‘Truly I tell you, in so far as you did it for one of the least in the estimation of men, my brothers, you did it for me.’” —Matthew 25:40 AMP

Meet Juan

J

uan is a sixty-­three-­year-­old Catholic man who lost his wife, Lynn, to ovarian cancer eighteen months ago. He became depressed after she died, withdrew from his friends, and stopped engaging in activities he used to enjoy, including his lifelong passion for cooking. Juan has attended mass at the same cathedral for the last twenty-­seven years, although not as regularly as he had before Lynn died. He prays daily and is intentional about using his faith to guide the way he lives his life. His priest, suspecting depression, suggested he work with a therapist. This excerpt is from his fifth session of CCBT. Juan: It just isn’t the same without Lynn. We did everything together for almost fifty years. Life is empty without her. Therapist: I can only imagine how empty and lonely it must feel losing your childhood sweetheart. Juan: I lived to love her and make her happy. We felt lucky to have one another, even after all those years. We retired early

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and planned to travel the world together. Then she got cancer and died a year later. Now I think, What’s the point? Therapist: I know this isn’t what you thought life was going to be like at sixty-­three. Juan: I wish God would show me why he left me here on earth, because my life doesn’t have much purpose without her. Juan is grieving the loss of more than just his wife; he’s grieving the loss of his dreams and the meaning and purpose he ascribed to his life. Juan used to find purpose in serving his wife. Now he needs another reason for living, which may include finding another way to serve others. Indeed, we will see that serving others is a useful tool for treating depression because it can generate positive emotions by changing what we pay attention to and the types of behaviors in which we engage. This chapter explores why approaching service from a CCBT perspective can be a more effective approach than conventional CBT for Christian clients like Juan who need to find new meaning and purpose in life.

Scientific Support for Serving Others It’s not news that receiving support from others helps us better cope with stressful life events, or that this support has a positive impact on our mental and physical health. Extensive scientific support exists for these associations. A more recent discovery, at least in the empirical literature, is that providing help and support to others is also good for our health. Indeed, being generous and enhancing the well-­being of others is associated with less depression, hopelessness, and stress. In fact, some research shows that people who help others have better mental health than those who receive help, even after controlling for other factors like stress that might have helped to explain these associations.1 Helping others is also related to greater perceived meaning and purpose in life, better health, higher self-­ esteem, and greater compassion and satisfaction with one’s relationships.2 Several studies have even found that people who give more

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emotional and practical support to others live longer than those who give less support to others.3 To understand why serving others has a beneficial effect on our own health, and not just the health of the one being served, it can be instructive to think about how we feel when we do something kind for another person. We usually feel useful and experience a sense of belonging and connection. We’re engaged and involved rather than isolated and inactive. We probably don’t think much about our own struggles or perhaps even begin to see our current challenges in a more positive light, as more manageable or not nearly as bad as it could be. All of these feelings and experiences are related to better health. Research has also found that when we help others we release oxytocin, a hormone that reduces the stress response.4 Thus, on an emotional, mental, and physiological level, serving is good for everyone involved. Most of us know about, if not try to live by, what is known as the Golden Rule: Do unto others as you would have them do unto you. People do good deeds for others for many different reasons. Some scientists argue that humans are inherently self-­serving and that altruistic acts are ultimately done because of how they make us feel, not how they make the other feel. Others assert that altruism is an evolutionary advantage. By assisting our kin, we help to ensure their and our survival. What these arguments fail to explain is why people do things for others at a cost to themselves, when there is no present or future advantage for the giver. Scholars and theologians suggest that the tenets of religious faith provide a compelling reason and motivation for these sacrificial altruistic acts. Some empirical research supports this idea. People who identify as religious are more likely to report being generous and engaging in volunteer work and charitable giving.5 Love for God, your neighbor, and yourself is at the core of Christianity. As such, Christians have a set of spiritual instructions to be generous, as well as the sense that God notices if and how these instructions are being followed.6 Christians, therefore, have unique religious motivations to love and serve God and others. Our research group found that religious cli-

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ents who participated in CBT that included a focus on generosity (using the same activity discussed in this chapter) reported more generosity at the end of treatment, and greater generosity predicted a reduction in depressive symptoms.7

Christianity and Serving Others When Jesus was asked by one of the religious experts of his time what was the greatest commandment, he answered, “Love the Lord your God with all your heart and with all your soul and with all your mind.” The second greatest commandment, He said, was to “Love your neighbor as yourself ” (Matthew 22:37, 39). In fact, these commandments were deemed so important that Jesus told the man that every other commandment hung on or could be fulfilled by following these two. No wonder it’s called the Great Commandment! As the greatest commandments in Christianity, followers of Christ need to know what exactly it means to love. Is it that good feeling we get when we are around people we like? Is it thinking fondly about someone all day long? Is it saying, “I love you”? Thankfully, Jesus didn’t leave his followers in the dark. He provided a definition of love a few chapters later in the Gospel of Matthew. Here Jesus equates loving with giving food to the hungry, drink to the thirsty, lodging to the stranger, clothes for the naked, and company for the imprisoned. In other words, in Christianity, love means serving others. But even more significantly, Jesus goes on to say, “Truly I tell you, in so far as you did it for one of the least in the estimation of men, you did it for me” (Matthew 25:40). Therefore, for Christians, loving God is expressed by loving and serving others, especially those who are disadvantaged and disenfranchised in society. Doing so is believed to be recognized as service done unto God himself.

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Religiously Integrated Service Skill-­Building Activities A session on generosity and service has at least two main goals from a CCBT perspective. The first is to demonstrate to our clients how and why service can help generate a positive mood. The second is to learn explicitly about and activate our clients’ own religious motivations to engage in acts of service. Here is one way you might introduce generosity and service to your clients: Have you ever experienced that warm feeling inside after helping someone? Well, we now have scientific data showing that helping others really does make us feel better. In fact, sometimes supporting others can be even better for our well-­being than receiving support. So, another tool that can assist you in overcoming depression is being generous and serving others.

Noticing the Relationship between Serving and Mood To begin a dialogue on service with our clients, we can ask them to tell us about a time when they helped someone, either formally, such as through a volunteer organization, or informally, such as looking after a neighbor’s dog for the weekend. We can use this example to draw attention to the association between their mood state before and after their act of service. If clients are unable to think of an example, we can pose a hypothetical situation and ask how they might expect to feel. Or we could ask them if they have ever observed an act of service and noticed an impact on the giver’s mood.

Assessment of Service Behaviors After this conversation, we can inquire about what types of formal or informal service behaviors clients are currently doing or used to do. It is not uncommon for the answer to be “few” or “none” for current service activities, given the nature of depression, with

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symptoms including apathy, inactivity, and social isolation. Providing information about how depression can impact one’s focus on and service for others can help lessen any shame or defensiveness clients might be feeling at this point. The goal of this assessment is simply to establish a baseline, or starting point, for current service behavior upon which our clients can build. Next, we can assess whether service is or is not related to their Christian faith and identity. For example, we might ask, ▶▶ “Is serving others a value of yours? If yes, how so?” ▶▶ “In what way, if any, does your Christian faith play a role in how you view service to others?” ▶▶ “Would you like to explore what Christianity says about helping others?” This assessment can be eye-­opening for clients, as it may be the first time they realize how disconnected they have become from an important component of their religious identity. We can reassure them that it doesn’t have to remain this way, and that as they begin to help others they are likely to experience an improvement in well-­being.

Motivation for Service Although our clients need to know that generosity can lead to a lessening of depression, emotional benefits are not the only motivator. When working from a religiously integrated approach, we help our clients access their religious worldviews to provide a broader and arguably more powerful motivation to serve. For Christian clients, possible religious motivations include loving God by serving others, developing humility, and becoming more like Christ. These are core principles and values of the Christian faith. Here’s how we might begin a conversation about the ways our clients’ faith can motivate them for service: Loving and serving others are among the defining features of the Christian faith. When a young man asked Jesus what was the greatest commandment, Jesus replied, “Love the Lord your God with all

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your heart, mind, and soul; and love your neighbor as yourself.” He also told his followers that just as they had freely received, they were to freely give back to others. What do you think Jesus meant when he said to love our neighbors and to freely give back to others? How do we do that?

One way to help clients more firmly connect their desire to help others to their Christian faith is to read and discuss the scripture passage in which Jesus states that everything we do for others is actually being done as unto God himself. This passage also illustrates that there are many ways to serve others, some of which are small and might seem insignificant. Clients may or may not be familiar with this passage in the Gospel of Matthew. As with other scriptural references, it can be beneficial to read this passage together.

= “For I was hungry and you gave Me food, I was thirsty and you gave Me something to drink, I was a stranger and you brought Me together with yourselves {and} welcomed {and} entertained {and} lodged Me, I was naked and you clothed Me, I was sick and you visited Me with help {and} ministering care, I was in prison and you came to see Me. Then the just {and} upright will answer Him, Lord, when did we see You hungry and gave You food, or thirsty and gave You something to drink? And when did we see You a stranger and welcomed {and} entertained You, or naked and clothed You? And the King will reply to them, Truly I tell you, in so far as you did it for one of the least [in the estimation of men] of these My brethren, you did it for Me.” —Matthew 25:35–40 AMP

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After reading this passage, we can ask our clients what they think of the idea that all of their actions are done as to Jesus himself. Questions we might ask include, ▶▶ “In what ways do you agree or disagree with this teaching?” ▶▶ “How might this teaching bring more meaning to your service?” ▶▶ “In what ways could this teaching make service more rewarding?” It is difficult to focus on others and to engage in activity of any sort when depressed. As such, helping our clients to explore their religious beliefs and values around service may provide the boost they need to engage in these mood-­enhancing behaviors.

Clinical Caveat and Caution A few notes of caution should be mentioned. First, clients could possibly interpret the scriptural texts and discussion of religious motivations as evidence that they are “bad Christians,” either because they are not currently serving others or not serving “enough,” or because they simply don’t feel like serving. Clients with depression may be at particular risk of making these interpretations because the depressive mental filter is negative and self-­condemning. We need to assess for such interpretations, for if they are not identified and challenged, our clients may end up feeling worse after the session. Sharing scriptural passages about God’s love, grace, and unconditional acceptance (e.g., John 3:17; Romans 8:1, 38–39) can help clients counter negative interpretations about their current level of service. Second, beyond possible religious condemnation, some clients have a history of doing too much for others and too little for themselves. Some are already giving all they can in caring for children or parents in need of assistance. In these cases, it is better to attend to ways our clients can take care of and love themselves. The Great Commandment says that we are to love our neighbors as ourselves; this passage can be referenced and discussed during such a conversation.

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Act of Service Exercise: Giving Back In the Giving Back exercise, we collaboratively plan and schedule an altruistic act for the client to engage in over the next week. The worksheet provided at the end of the chapter can be used for this purpose.

Choosing the Activity To begin, we brainstorm with our clients possible ways they can serve others. For example, they might give of their time, energy, resources, skills, or expertise. It can be helpful to prime the pump, so to speak, by reviewing ways they have helped others in the past. For this process, we can encourage the client to join us in naming as many options as possible without commentary. This can help maintain momentum once ideas start coming. Once the brainstorming list is compete, we can ask the client to rank each item for level of difficulty, and then ask the client to choose one of the easier items on the list to complete this week. This approach helps ensure a set-­up for success. Planning the Activity Planning a concrete and specific activity makes engaging in the behavior feel less overwhelming and ambiguous, and as a result increases the likelihood it will be completed. We can help our clients plan an activity that is as realistic and achievable as possible by discussing the following questions together: ▶▶ Who will be helped? ▶▶ What activity will be completed? ▶▶ When and where will it be completed? ▶▶ What is needed to compete the activity? ▶▶ How often will the activity be completed? ▶▶ What potential barriers and problems could get in the way? ▶▶ How will you deal with these potential problems?

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Setting an Intention In addition to ensuring that the activity is achievable, we need to review with our clients their intention for completing it. A helpful reminder is that although they may receive appreciation and perhaps even a reward from the person they help, this response is not guaranteed. As such, this type of motivation might function to extinguish rather than repeat the altruistic behavior in the future. In setting an intention to serve rooted in our clients’ religious beliefs and values, we might discuss how Jesus modeled service. In the Gospel of Mark, Jesus is recorded as saying, “Whoever desires to be great among you must be your servant. And whoever wishes to be most important . . . among you must be the slave of all. For even the Son of Man [Jesus] came not to have service rendered to Him, but to serve and give His life as a ransom for many” (Mark 10:43–45 AMP). In Christianity, service is portrayed as an act of humility and sacrifice, something that is pleasing to God, and is ultimately rewarded by God. Assessment of the Activity’s Impact Before and after completing the activity, we ask clients to rate their mood on a scale of 1 to 10. This data can be used to assess and ideally reinforce the effect of generosity on reducing depressive symptoms. Then, in the following session, we review with our clients the completion of the activity, the impact it had on their mood, and the likelihood they will engage in future altruistic acts. We can also discuss if and how this activity affected their identity as a Christian and their relationship with God, as we know spiritual well-­being and growth can be important clinical outcomes for our religious clients.

Clinical Application Let’s return to the case about Juan and see how approaching service from a faith-­based perspective can help clients find (renewed) meaning and purpose for their lives. Watch how the therapist helps

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Juan engage his religious motivations for serving others, as well as for challenging a depression-­maintaining belief. Notice also how the therapist helps Juan use the tool of Giving Back by planning a specific act of service and helping him think through the what, when, where, how, and why of this act. Therapist: Tell me more about how you used to volunteer at the homeless shelter on Thanksgiving. Did you enjoy doing that? Juan: Oh, yes. It used to be something we looked forward to each year. I’m a closet chef, you know, and I used to prepare so much more than the simple turkey and canned beans and corn most shelters provided. I thought by serving the men a gourmet dinner they’d feel special even if no one else in their life told them that. You should have seen the smiles on their faces. Therapist: I’m sure they really appreciated that. When was the last time you did this? Juan: It’s been a little over two years now. I don’t feel motivated to go without Lynn. I feel so sad myself, and no one wants to be around someone who is depressed. I would just depress the men even more. Therapist: You have the assumption that if you’re feeling depressed, others don’t want to be around you—that you couldn’t be helpful. Juan: Yes, I’m know I’m a downer right now. Those men have enough sadness in their life. They don’t need me adding to it. Therapist: Can we look at that assumption more closely—that you will bring the men down because you are feeling sad? Juan: It doesn’t feel like an assumption, but sure. Therapist: Let’s use the ABCD(R)E approach. We’ve got the belief that serving dinner to the men at the homeless shelter while I’m sad will cause the men to feel sad. How does this belief make you feel?

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Juan: More sad. Disappointed, too, because I used to like doing this. Therapist: What rating would you give for sadness? What about disappointment? Juan: Maybe a 6 or 7 for both. Therapist: Okay, let’s see if we can challenge this assumption. First, what evidence do you have that this belief is true? Juan: I don’t think I’d feel any better if I were around someone who is sad. I would imagine others feel the same way. Therapist: Have you tested this out? Been with someone who is sad? Juan: Well, our friends were all sad when Lynn died. But come to think of it, it was sort of comforting to know they felt sad. I felt less alone with that feeling. Therapist: This sounds like some evidence against the belief you’d bring others down with your sadness. Juan: Yes, I guess it is. They were sad because Lynn died, not because I was sad. Therapist: [Uses Step R] What about your religious resources, your beliefs and practices as a Christian? Can any of those provide more evidence against the assumption that you will bring the men down because you are grieving? Juan: I know Jesus taught we are to love one another. That’s what used to motivate me to serve in the first place. I suppose he didn’t say to only love people when we’re feeling good. Therapist: That’s a very good point. Jesus didn’t qualify the Great Commandment by saying we are only to follow it when we are feeling good. Do you remember Jesus’s teaching about how when we do something for the least of these we are actually doing it unto him?

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Juan: Just vaguely. Therapist: Would you like to have a look at that passage? I think it ties in nicely with what we’re talking about. [Juan uses his smartphone to look up Matthew 25:35–40 and reads the passage out loud.] Therapist: What are your thoughts on this passage? Juan: My first thought was that this is pretty incredible. This means when I make food for these men, I am actually making food for God. Therapist: That is a pretty incredible idea. Do you think it would make God sad if you made food for him when you’re sad? Juan: [laughs] No, of course not. In fact, maybe it would please him even more if I’d be willing to do that when I’m not feeling great myself. Therapist: I think you’re probably right, that it’s a pleasing sacrifice to God. Juan: Who knows, maybe being there and serving would get my mind off my own loss for a while? Therapist: It would be an interesting experiment to try. The research shows that when we help others we often end up feeling better ourselves. In fact, some studies have found it’s even better to give help and support than to receive it. Being generous and serving others is another tool we can use to help improve our mood. And, as we’ve seen, it’s a tool that is rooted in your personal belief system. Juan: I think it’s worth trying. Thanksgiving isn’t for another six months, but I’m sure the shelter would be open to having help anytime. I just don’t know if I’m up for researching a new recipe and making something elaborate like I used to.

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Therapist: What if making a simple, nutritious meal was enough? What would be easy for you to make? Juan: I make a good beef stew. That would feel less overwhelming than something complicated. Therapist: Perfect. When would you like to do this? Juan: I think Saturday would be best for me. I’d need to call the director of the shelter and see if that would work for them, though. Therapist: Today is Monday. What do you need to do between now and Saturday to prepare? Juan: I’ll need to speak with the director, find out how much food to buy, go grocery shopping, and then arrive early on Saturday to make the stew so it’s ready by dinnertime. Therapist: If you find this is not enough time or you are starting to feel overwhelmed, what can you do? Juan: I can just ask to push it back another week so I have some more time to prepare. Therapist: This sounds like a great plan. You seem lighter just talking about it. Juan: It feels good to think I can still be useful. It won’t be the same without Lynn, but I know she’d be proud of me for doing this. It’s one way I can still make her happy. And it’s a way I can make God happy. I’d say that’s a pretty good deal. The following week, the therapist checked in with Juan regarding his act of service. Juan smiled as he recounted how he had prepared the beef stew and how much the men enjoyed it. He said he felt sad arriving without Lynn, but he “forgot” about being sad while he was in the kitchen preparing the meal and noticed he even felt happy when he watched the men eating it. He said the experience made

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him feel closer to God. When he set the plate down in front of each resident, he imagined he was setting it down before God himself. He had already set up a date to prepare dinner for the men next month. It was important for Juan to make the connection between the teachings of Christ and helping others. Realizing it didn’t matter to God whether he was sad or not, and knowing that his sacrifice would make God happy, gave him the motivation he needed to begin serving again. By working with Juan to engage his religious motivations and values around a specific act of service, Juan experienced a positive cognitive change, less social isolation, and a renewed sense of meaning and purpose, all of which contributed to an improvement in his mood.

= Tool Summary Clients can employ the Giving Back: Service tool by completing the following activities: ▶▶ Exploring religious motivations for serving others ▶▶ Planning and completing a specific act of service

The following worksheet is designed to help you brainstorm ideas and then plan a specific activity that you can develop to serve others. Complete sections 1–4 before your service activity begins. Section 5 should be completed after you have finished your service activity. Figure 10.1. Giving Back: My Service Activity 1. Brainstorm a list of ways you could serve others. These might be things you have done in the past or have witnessed others doing. Be concrete and specific.

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2. Rank each item on your list for level of difficulty on a scale of 1 to 10 with 10 being the most difficult for you to complete. Then choose one of the activities you ranked as being less difficult (rating between 1 and 5) to complete this week. The service activity I will complete is

The person(s) I will help is

When and where will the activity be completed? (Day, time, place, more than once?)

What do I need to complete the activity?

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What potential barriers and problems could get in the way of completing this activity?

How will I deal with these potential problems?

3. Set an intention for completing the activity. What makes you want to engage in this service activity? Does your faith play a role in your desire to serve others? If so, how?

4. Immediately before the activity: Rank your mood on a scale of 1 to 10, with 10 being the best mood you can imagine and 1 being the worst.

5. Immediately after the activity is completed: Rank your mood on a scale of 1 to 10. Was there a change in your mood? If yes, why do you think this is so?

Chap t er 11

Conclusion and Relapse Prevention

C

hristian Cognitive Behavioral Therapy is an empirically based treatment for depression that acknowledges, assesses, and takes into account the lens through which many of our Christian clients view the world—their religious worldview— and how this lens influences their presenting symptoms, engagement in treatment, and recovery. Now that we have examined the seven CCBT tools in detail, it seems fitting to reiterate that although CCBT is a tool-­based approach, it is also an inherently client-­ centered approach. Therapists assist their clients in identifying and harnessing their own particular set of religious beliefs and practices. They may share religious references, scriptures, or stories throughout treatment, but CCBT therapists do not prescribe a certain set of beliefs and practices, and they certainly do not proselytize. CCBT is also client-­driven in that the structure of treatment is individually crafted to fit each client’s unique situation. In other words, there is no one set way to implement CCBT. We may use some or all of the seven tools outlined in the preceding chapters with a particular client. Which tools we choose, as well as the timing in which we introduce them, will depend on the individual client and his or her particular needs and treatment plan. We may find ourselves spending longer on some tools or circling back to a tool introduced earlier in treatment. I have presented the tools in this book in an order similar to that of the ten-­session CCBT treatment we used in our multisite randomized clinical trial. This may be the optimal progression for the introduction and use of the tools, but for now this remains an empirical question waiting to be answered.

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Summary of the Seven CCBT Tools Tool 1. Renewing Your Mind: Planting Truth. Fill the mind with positive and life-­giving truths through mind-­renewing activities, such as scripture memorization and contemplative prayer. Tool 2. Changing Your Mind: Metanoia. Change the mind by learning theological refutations for common cognitive distortions, and challenging and replacing negative and unhelpful thinking with the truth. Tool 3. Finding God and the Blessing in Suffering: Redemptive Reframing. After acknowledging and exploring spiritual struggles and sacred losses, reframe suffering by taking a larger, faith-­filled perspective of problems and actively searching for God at work in one’s life. Tool 4. Reaching Out and Connecting. Combat social isolation and a lack of purposeful activity through involvement in a religious community. Tool 5. Letting Go and Letting God: Acceptance and Forgiveness. After exploring hurts and resentments, as well as distressing issues beyond one’s control, use forgiveness and active surrender to find inner freedom and healing. Tool 6. Saying Thanks: Gratitude. Cultivate gratitude, an attitude and emotional state incongruent with depression, by noticing the blessings one has been given and expressing gratitude to God and others. Tool 7. Giving Back: Service. Shift the focus off of oneself and one’s problems by extending love and generosity to others through acts of service.

Relapse Prevention Once clients’ depressive symptoms have remitted and the active phase of treatment is complete, we move into a phase called relapse prevention. During relapse prevention, we review with our clients the progress they have made, what tools they used to achieve this

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progress, how to maintain these gains, and what to do if they find their mood worsening in the future. In this review, we seek to bolster our clients’ sense of agency, helping them to take credit for the changes they have experienced. It is best to discuss the steps our clients took in concrete language so that they have both a clear understanding of how they recovered and a game plan for the future. For example, a client who replies to the question, “What helped you to feel better?” with “I became more active,” has only an abstract idea of how he effected change. Given an abstract response like this one, we should ask the client to specify exactly what activities he engaged in, as well as his motivation for doing so. Concrete and specific responses sound more like the following: “I volunteered at the homeless shelter because I knew it would be something that pleased God, and I noticed my mood was much better while I was there”; or “I met with and prayed for a disabled person at church and it felt good to get my mind off of my own problems”; or “I wrote a letter thanking my high school English teacher for all the help she used to give me.” We can then draw attention to and review the specific CCBT tool to which each of these behaviors corresponds. In this case, the tools would be Giving Back: Service; Reaching Out and Connecting; and Saying Thanks: Gratitude. The same principle of making the abstract concrete holds true not just for the tools used to change clients’ behaviors but also for those used to change their thinking styles. For example, clients may attribute their feeling better to “thinking more positively.” Although true, this response is vague and does not describe the tool or steps they used to actually change their thinking. This is a good time to review each of the cognitive-­focused CCBT tools used in treatment: Renewing Your Mind: Planting Truth; Changing Your Mind: Metanoia; Finding God and the Blessing in Suffering: Redemptive Reframing; and Letting Go and Letting God: Acceptance and Forgiveness. To maintain changes and prevent relapse, clients need to continue to use the CCBT tools they learned. We can liken this process

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to weight lifting at the gym. To maintain the definition and muscle mass we worked so hard to attain, we need to continue to lift weights on a regular basis. Similarly, for clients to keep their thoughts adaptive and truthful and their mood positive, they need to continue to renew their minds with the truth, change their minds when they discover untrue or unhelpful thinking, engage in redemptive reframing, and practice acceptance and forgiveness. In addition, they should continue to find both big and small ways to practice gratitude, serve people, and reach out and connect with others in their faith community. Before treatment concludes, we should brainstorm with our clients ways that they can continue to practice their CCBT skills on a weekly, if not daily, basis. These ideas can be recorded on a worksheet labeled relapse prevention and added to their CCBT binder. If clients notice that their mood is slipping or other symptoms of depression are returning, the relapse prevention list and the CCBT binder in general can be excellent resources to help them get back on track. Like exercising, the more we do it, the more muscle memory we build. If we skip our workouts for a while, getting back to the good place we were doesn’t take as long the second time. In the same way, the more that clients practice their CCBT tools, the easier it will be to resume their use and experience the benefits, should they find themselves off track (see figure 11.1). Relapse Prevention

figure 11.1

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Hope A discussion about hope is a fitting way to conclude CCBT. Hope is not only a virtue in the Christian faith, but it is also described in scripture as an “anchor for the soul” (Hebrews 6:19). When clients intentionally create and reflect on their future dreams and goals, they are creating an anchor for their soul—a hopeful attitude and mindset that will help hold them fast and persevere when they are faced with the inevitable challenges of life or a resurgence of depressive symptoms. During this discussion, we can ask them at what point in treatment did they begin to feel hope that they would recover, how their Christian faith informs their hope, and how to maintain a sense of hope even in distressing and discouraging situations.

= May the God of your hope so fill you with all joy and peace in believing [through the experience of your faith] that by the power of the Holy Spirit you may abound {and} be overflowing (bubbling over) with hope. —Romans 15:13 AMP

Next Steps After we have completed the relapse prevention phase of treatment, we can either terminate treatment or, if necessary, change the focus of treatment to another issue that is causing our clients significant distress. A third option when working with religious clients who are interested in ongoing support and spiritual care is to transition them to receive such care from their pastor or other clergy member in their religious community. If they do not belong to a religious community but would like spiritual support, we can help them with

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an appropriate referral. This is another reason why it is prudent to have a list of clergy members in the area with whom we have established a working relationship.

When to Change Approaches or Seek Consultation with Clergy Being a competent therapist means knowing when a certain approach is not working or is contraindicated and then changing the treatment plan and approach accordingly. Sometimes a client may desire and consent to CCBT and later decide that this is not the right approach for him or her. In this circumstance, we want to understand why she or he feels this way—as this is important clinical information—and to collaboratively choose another type of treatment. At other times, it may be us rather than the client who voices concern about the appropriateness of CCBT. Here again we should have an open discussion with our client about what we have noticed and seek his or her feedback. For example, a client may find that CCBT activates memories of a traumatic experience in church, such as being sexually abused, and working within a religious framework in psychotherapy proves to be distressing rather than helpful. Or during the course of treatment, something may occur that shakes the client’s religious worldview, such as a pastor being caught having an affair. CCBT may be particularly helpful in processing this event. On the other hand, the client may desire some space from matters concerning religion. Below is a list of warning signs that CCBT may not be the appropriate approach for a client at this particular time or that consultation with or referral to clergy is necessary. Let me be clear, these signs do not necessarily mean that CCBT is the cause of the following concerns or that CCBT should be discontinued. It does mean that consultation with clergy, peer supervision, more training in CCBT, a referral for spiritual care, or a dialogue with your client— and in many cases, all of the above—needs to occur. ▶▶ Religious references or material makes the client angry or

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defensive. ▶▶ The client engages in therapy distancing or disruptive

behaviors, such as being late, missing appointments, or not doing home practice activities. ▶▶ Onset of nightmares or an increase in anxiety. ▶▶ Religious hallucinations or delusions. ▶▶ A regression in behavior or more childlike demeanor. ▶▶ The client feels condemned and that cognitive restructuring is not helping. ▶▶ The focus of therapy goes from treating depression to spiritual growth or care. ▶▶ The client provides feedback that it feels like you are trying to convert him or her. ▶▶ You get the sense the client is choosing CCBT because she thinks this is what you want or what a “good Christian” would do. ▶▶ You find yourself integrating your own beliefs, rather than those of your clients.

Final Words As we have seen, to be an effective practitioner of CCBT you do not need to be religious. Although some familiarity with biblical texts and teachings can be helpful, a practitioner’s own spiritual experiences and faith beliefs do not qualify as competence in delivering spiritually integrated therapy. To be a competent practitioner in any therapeutic approach, including CCBT, it takes training, ongoing learning, supervision, and practice. Feeling a little uncomfortable at first is normal, as it is with any new and unfamiliar way of doing things. Remember that your clients are the experts on what they believe and practice, and you do not have to (and shouldn’t) do this on your own. Consult with clergy and seek out supervision from peers who have had experience integrating religion into therapy. Also, remember that your main goal is psychological—to treat depression. Spiritual growth may occur along the way, but that is

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not the focus of therapy. Finally, self-­reflection is critical in becoming an effective practitioner of CCBT. We need to be conscious of judging clients who believe or practice their spirituality differently from ourselves, as well as a tendency to persuade them to be more like us. The more you know about yourself in regard to religion and spirituality, the better you will be at recognizing and avoiding biases, positive and negative. Integrating Christianity into psychotherapy might be a new endeavor for you or it might be something you have done regularly for years. My hope is that, wherever you are on the continuum, this book has provided some new ideas and helpful tools to assist you in the remarkable work you do. Our clients come to us looking for hope and healing, and engaging in this work can feel like a daunting task at times. Those clients who have chosen to follow Christianity have a powerful set of beliefs and practices that can greatly assist them in their quest for hope and healing. Our job is to acknowledge this potential resource and, for those who so desire, to help them harness it by integrating their faith, values, and religious practices into psychotherapy. CCBT is a treatment approach that does just that, helping our Christian clients who feel downtrodden and discouraged find healing, hope, and wholeness.

Appendix A

For Clergy Recognizing Depression

A

s clergy, you are responsible for much more than simply pre paring and delivering the Sunday sermon. In fact, for many of you, the majority of your time is devoted to ministering to your congregants’ spiritual and emotional needs. You make hospital visits and home visits, officiate weddings and funerals, and perform ceremonies for births and baptisms. You counsel happy, starry-­eyed-­ in-­love engaged couples, as well as bitter, one-­foot-­out-­the-­door married couples. In other words, people ask you to share in the best and the worst moments of their lives. As such, you are particularly well-­positioned to intervene when your congregants are suffering from clinical depression. To do so most effectively, you first need to be astute in recognizing the symptoms of depression. Below is a list of warning signs for depression. The more warning signs that individuals exhibit, the greater the likelihood that they are experiencing depression. This list is provided not for diagnostic purposes, but rather to equip you to notice when a referral to a mental health professional is warranted. Mental health professionals have received extensive training, as well as state licensure, to diagnose and treat psychological disorders. Warning Signs for Depression ▶▶ Low mood or persistent sadness ▶▶ Feeling empty ▶▶ Loss of interest or pleasure in things that used to be enjoyable

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▶▶ Irritability ▶▶ Tearfulness and crying spells ▶▶ Significant changes in appetite or weight ▶▶ Difficulty sleeping or oversleeping ▶▶ Restlessness or moving and speaking much more slowly

than usual ▶▶ Fatigue or low energy ▶▶ Feeling worthless ▶▶ Feeling inappropriately guilty ▶▶ Difficulty concentrating ▶▶ Indecisiveness ▶▶ Memory problems ▶▶ Problems functioning at work or home ▶▶ Relationship difficulties ▶▶ Thoughts of or making plans for suicide or a suicide attempt

The Important Role You Play You can play an integral role in your parishioners’ treatment and recovery process. Christians can be reluctant to see a secular therapist for many reasons, as we discussed in chapter 1. They are much more likely to turn to their pastor or another clergy member for counseling, which means that you are in a position of influence. If you suspect that a parishioner is depressed, the way in which you discuss your concerns with him or her and describe the psychological treatment options available greatly determine whether that person seeks the needed mental health treatment. If you feel hesitant about referring your parishioner to a secular therapist, remember the research we reviewed in chapter 1: Christian clients receiving religiously integrated psychotherapy do just as well with secular therapists as they do with Christian therapists.1 Unexpectedly, in one study, Christian clients who received religious therapy from nonreligious therapists had a greater reduction in depression than those who received the same therapy from religious

appendix a: for clergy | 179

therapists!2 What matters is that therapists use religious interventions that match their clients’ level of religious commitment. Psychotherapy can be a means of strengthening Christian clients’ faith, religious identity, and spiritual well-­being. Research shows that religious clients who received spiritually integrated therapy had greater improvement in spiritual outcomes and similar improvement in psychological outcomes.3 If parishioners have your encouragement and blessing, so to speak, to seek professional help, they may be much more likely to do so. Furthermore, knowing that religiously integrated treatments such as CCBT are available in secular settings can be comforting as well as motivating for them. You might also suggest that they read this primer to get an idea of what is involved in CCBT and how their religious beliefs and practices will be not only respected but also an active healing ingredient in treatment. Your role in your parishioners’ recovery can continue well past this conversation and referral. Once your parishioner signs a release of information form, you and the mental health professional are permitted to discuss the person’s symptoms and treatment. Your guidance around religious and theological issues will be invaluable to the therapist, particularly for secular therapists who are using a religiously integrated treatment such as CCBT. Not only can you take on a consultant role with the therapist, but you can also continue to be a spiritual advisor for your parishioner, a role that therapists are not trained to play.

Making a Referral to a Mental Health Professional Have at hand a running list of mental health providers who are trained in religiously integrated therapies. That way when the occasion arises and your parishioner is still in the office with you, you can provide him or her with the contact information for a mental health professional you trust.

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To find a therapist who provides Christian CBT, you can search for a Christian therapist who uses CBT or a therapist who is already trained in CCBT. A few ways a Christian therapist can be located are as follows: ▶▶ National Christian Counselors Association www.ncca.org/ ▶▶ American Association of Christian Counselors www.aacc.net/resources/find-a-counselor/ ▶▶ American Association of Pastoral Counselors www.aapc.org An alternative is to find a therapist skilled in CBT who may already integrate religion into CBT or who would be willing to read a book like this one to learn how to do so. You can locate a CBT therapist on the Association for Behavioral and Cognitive Therapies website, www.abctcentral.org/xFAT/.

Appendix B

CBT and Christian CBT Resources

T

he following is a select list of resources available for additional training in conventional CBT and religiously integrated CBT.

CBT Training Resources Beck Institute for Cognitive Behavior Training Training opportunities include core curriculum workshops, specialty workshops for specific disorders or populations, supervision and consultation via Skype, and customized training programs for organizations; www.beckinstitute.org/cbt-­training/. Feeling Good Institute Offers online advanced CBT skills training and consultation for therapists; www.feelinggoodinstitute.com. The Association for Behavioral and Cognitive Therapies Provides training in CBT in the form of online courses, videos, webcasts, manuals, and books; www.abct.org/home/.

CBT Books and Resources Beck, J., and A. Beck. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed. New York: Guilford Press, 2011. Burns, D. Feeling Good: The New Mood Therapy. New York: Harper, 2008.

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Gilbert, P. Overcoming Depression: A Self-­Help Guide Using Cognitive Behavioral Techniques. New York: Basic Books, 2009. Greenberger, D., and C. Padesky. Mind over Mood: Change How You Feel by Changing the Way You Think. 2nd ed. New York: Guilford Press, 2015. Cognitive Therapy Today. Free newsletter published by the Beck Institute for Cognitive Behavior Training addressing CBT-­related topics, such as special populations and diagnoses and cross-­ cultural issues. Also provides information about speaking engagements and workshops. To sign up, go to www.beckinstitute.org/ cognitive-­therapy-­today/.

Religiously Integrated CBT Training Resources The Center for Anxiety. Offers onsite and audio recorded ­seminars and workshops on spirituality and mental health; www.center foranxiety.org/. National Christian Counselors Association. The NCCA trains, certifies, and licenses Christian counselors. Training can be completed either online or onsite at various academic institutions located worldwide; www.ncca.org/. American Association of Christian Counselors. The AACC is a network of state-­licensed, certified, or credentialed Christian counselors who identify as Christians and offer Christian counseling; www. aacc.net/resources/find-­a-­counselor/. American Association of Pastoral Counselors. The AAPC is a network of certified pastoral counselors who are licensed mental health professionals with extensive religious education and training; www. aapc.org.

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Religiously Integrated CBT Manuals and Workbooks Duke Center for Spirituality, Theology, and Health. Religiously integrated CBT manuals, therapist workbooks, and patient workbooks. Christian, Jewish, Muslim, Buddhist, and Hindu versions of each are available at no cost; www.spiritualityandhealth.duke.edu/index. php/religious-­cbt-­study/therapy-­manuals.

Religiousness and Spirituality Assessment Tools Hill, P. C., and R. W. Hood, Jr. Measures of Religiosity. Birmingham, AL: Religious Education, 1999. Daily Spiritual Experiences Scale (DSES) assesses the frequency of ordinary spiritual experiences, such as feeling connected to the transcendent; experiencing a sense of peace, awe, or joy; and being grateful (sixteen items);1 www.dsescale.org/. The Multi-­Dimensional Measure of Religiousness (BMMRS) consists of twelve scales measuring different aspects of religiousness and was originally meant for use in health research.2 The twelve scales are Daily Spiritual Experiences; Meaning; Values; Beliefs; Forgiveness; Private Religious Practices; Religious/Spiritual Coping; Religious Support; Religious/Spiritual History; Commitment; Organizational Religiousness; Religious Preference. The BMMRS is available free of charge at fetzer.org/resources/multidimensional-­measurement-­ religiousnessspirituality-­use-­health-­research. Intrinsic Religiosity Scale (IRS) is a ten-­item scale that measures the degree to which one’s religion is internally motivated by items such as, “My religious beliefs are what really lie behind my whole approach to life.”3

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Positive and Negative Religious Coping (Brief RCOPE) is a fourteen-­ item measure of how one uses religion to cope with life stressors.4 The scale has two subscales; positive religious coping assesses a secure sense of connection with a benevolent God and others in one’s religious community, and negative religious coping assesses spiritual struggles and stressors with the divine and others, and within oneself. The Index of Core Spiritual Experiences (INSPIRIT) is a seven-­item scale that measures a client’s experiences with God, including what convinces the client that God is real and lives within him or her.5 The Spiritual Well-­Being Scale (SWBS) assesses spiritual quality of life.6 Ten items measure religious well-­being (relationship with God), and ten items measure existential well-­being (life purpose and satisfaction). The following website compiled by Dr. Everett Worthington also has a long list of links to various scales on forgiveness, religious commitment, humility, and marriage and family relationships: www. evworthington-­forgiveness.com/assessment-­scales/.

Religiously Integrated Therapy Books and Articles Dowd, E. T., and S. L. Nielsen. The Psychologies in Religion: Working with the Religious Client. New York: Springer Publishing, 2006 Hodge, D. R. Spiritual Assessment: Handbook for Helping Professionals. Bootsford, CT: North American Association of Christians in Social Work, 2005. Hood, R. W., Jr., P. C. Hill, and B. Spilka. The Psychology of Religion: An Empirical Approach. 4th ed. New York: Guilford Press, 2009. Koenig, H. G., D. E. King, and V. B. Carson. Handbook of Religion and Health. 2nd ed. New York: Oxford University Press, 2012.

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Kruis, J. G. Quick Scripture Reference for Counseling. 3rd ed. Grand Rapids: Baker Academic, 2000. McCullough, M. E., and K. I. Pargament. Forgiveness: Theory, Research, and Practice. New York: Guilford Press, 2000. Miller, W. R. Integrating Spirituality into Treatment: Resources for Practitioners. Washington, DC: American Psychological Association, 2000. Pargament, K. I. Spiritually Integrated Psychotherapy: Understanding and Addressing the Sacred. New York: Guilford Press, 2007. Pearce, M. J., and H. K. Koenig. “Cognitive Behavioral Therapy for the Treatment of Depression in Christian Patients with Medical Illness.” Mental Health, Religion, and Culture 16, no. 7 (2015) 730–40; dx.doi.org/10.1080/13674676.2012.718752. Pearce, M. J., H. G. Koenig, C. Robins, B. Nelson, S. Shaw, H. Cohen, and M. King. “Religiously Integrated Cognitive Behavioral Therapy: A New Method of Treatment for Major Depression in Patients with Chronic Medical Illness.” Psychotherapy: Theory, Research, and Practice, 52, no. 1 (2015) 56–66: dx.doi.org/10.1037 /a0036448. Richards, P. S., and E. D. Bergin (eds.). Handbook of Psychotherapy and Religious Diversity. Washington, DC: American Psychological Association, 2000. ———. A Spiritual Strategy in Counseling and Psychotherapy. Washington, DC: American Psychological Association, 2005. Shafranske, E., ed. Religion and the Clinical Practice of Psychology. Washington, DC: American Psychological Association, 1996. Sperry, L., and E. P. Shafranske, eds. Spiritually Oriented Psychotherapy. Washington, DC: American Psychological Association, 2005. Tan, S. Y. Counseling and Psychotherapy: A Christian Perspective. Grand Rapids: Baker Academic, 2011.

Appendix C

Reproducible Resources The Seven CBT Tools Tool 1. Renewing Your Mind: Planting Truth. Clients begin by learning how to fill their minds with positive and life-­giving truths through mind-­renewing activities, such as scripture memorization and contemplative prayer. Tool 2. Changing Your Mind: Metanoia. This modified classic CBT tool equips clients to take all thoughts captive by learning theological refutations for common cognitive distortions, and challenging and replacing negative and unhelpful thinking with the truth. Tool 3. Finding God and the Blessing in Suffering: Redemptive Reframing. After acknowledging and exploring spiritual struggles and sacred losses, this tool helps clients to reframe their suffering by taking a larger, faith-­filled perspective of their problems and actively searching for God at work in their lives. Tool 4. Reaching Out and Connecting. This behavioral tool combats social isolation and a lack of purposeful activity by encouraging clients to be involved in a religious community and exploring ways of doing so. Tool 5. Letting Go and Letting God: Acceptance and Forgiveness. After clients explore their hurts and resentments, as well as the distressing issues in their lives that are beyond their control, they can use forgiveness and active surrender to find inner freedom and healing. Tool 6. Saying Thanks: Gratitude. This tool helps clients cultivate gratitude, an attitude and emotional state incongruent with depres-

188 | appendix c: reproducible resources

sion, by noticing the blessings they have been given and expressing their gratitude to God and others. Tool 7. Giving Back: Service. With this behavioral tool, clients shift their focus off of themselves and their problems by extending love and generosity to others through acts of service.

appendix c: reproducible resources | 189

CBT Model

figure 3.1.

CCBT Model

figure 3.2.

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Figure 5.1. Ten Common Distorted Thinking Styles 1. All-­or-­Nothing Thinking You see things in black-­and-­white categories. For example, if your performance falls short of perfect, you see yourself as a total failure. This way of evaluating things is unrealistic because life is rarely completely one way or the other. Theological reflection: Jesus told his followers that they are to hate evil; yet he also said that they should love and pray for their enemies, rather than judge or condemn them for doing wrong. Extending grace to others seems to mean seeing the world in shades of gray, rather than in strict black-­and-­white terms. 2. Overgeneralization You see a single negative event as a never-­ending pattern of defeat. For example, if you are turned down for a job, you tell yourself no one will ever hire you. Theological reflection: In the Gospel of John, when Jesus was arrested, Peter denied ever knowing him. One might assume that Peter had failed as a friend and could never again consider himself worthy of friendship with Jesus. However, after the resurrection, Jesus engages with Peter in a loving manner and entrusts to him the sacred mission of sharing the gospel message with others. Peter openly proclaimed his love for Jesus for the rest of his life. One failure didn’t mean a lifetime of failure for him. 3. Mental Filter You pick out a single negative detail in a situation and focus exclusively on this. In doing so, you ignore or filter out any positive details or feedback.

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Theological reflection: Scripture gives clear instructions on what to focus our thoughts on: “Whatever is true, or lovely, or gracious . . . think on that. If there is any excellence, if there is anything worthy of praise . . . think about that” (Philippians 4:8). To do this, we need to acknowledge and reflect on the positive things we have been given and accomplished and the positive feedback we have received; we are not to ignore or filter these things out. 4. Disqualifying the Positive You disqualify positive experiences by insisting they “don’t count” for some reason. In this way you can maintain a negative belief that is contradicted by your everyday experiences. You don’t just ignore positive experiences as with the Mental Filter; you intentionally devalue them. Theological reflection: When the Israelites experienced hardships in the wilderness on the way to the Promised Land, they decided that God had rescued them from slavery in Egypt only in order to kill them in the wilderness (Exodus 16:3). They disqualified God’s promises and the miracles he had done on their behalf to deliver them and to sustain them in the wilderness. As a result of disqualifying these positives, they made an inaccurate assessment of God’s character and his purpose for rescuing them from the Egyptians. 5. The Fortune-Telling Error You jump to conclusions by anticipating that things will turn out badly. You feel convinced that your predictions are an already established fact even though no one can predict the future. Theological reflection: Jesus told his followers not to be anxious about the future because he is in control and has promised to take care of them (Matthew 6:25–34). By worrying and imagining a negative future, not only do we not improve the

192 | appendix c: reproducible resources

situation, but we also act as if we do not trust God to keep his promises. 6. Catastrophizing You inappropriately exaggerate the importance of things, such as thinking that a mistake you made was the worst possible outcome. By distorting reality, things appear worse than they are. Theological reflection: After Judas betrayed Jesus, he felt so guilty that he saw no solution for his actions other than killing himself. Although his actions were certainly grievous, Jesus had a history of demonstrating grace and forgiveness. Indeed, restoration of humankind’s right relationship with God was the purpose of Jesus’ death and resurrection. Judas’s interpretation of his action was a distortion of reality, one that cost him his life. 7. Emotional Reasoning You assume that your negative emotions necessarily reflect the way things really are: “I feel it. Therefore, it must be true.” Our emotions are a reflection of our thoughts, beliefs, and physiology; they are not necessarily a reflection of the true state of affairs. Theological reflection: Individuals in the Bible are described as having times of dryness and darkness, times when they yearned for God, but did not feel his presence. However, not feeling God’s presence did not mean he was absent, because God says he will never leave or abandon us. Their feelings of being alone were not a true reflection of the situation. We are asked to put our faith in God’s promises, not in our feelings. 8. Should Statements You try to motivate yourself with shoulds and shouldn’ts, as if this is the only way you can get yourself to do something. When you don’t do something you think you should have done, you

appendix c: reproducible resources | 193

feel guilty. When you direct should statements toward others, you feel anger, frustration, and resentment. Theological reflection: One of the central themes of the New Testament is that Christ has accepted us, forgiven us, and given us a spirit of freedom. As such, there is no need to condemn ourselves if we do not perform the way we or others think we should have performed (Romans 8:31). If we make a mistake, the Bible says that we are to confess our sin to God and that He immediately forgives us and puts that sin as far away as the East is from the West. His love is a gift of grace, not a result of us earning or deserving it. 9. Labeling This is an extreme form of overgeneralization. Instead of describing your error or behavior (e.g., I failed the exam), you attach a negative label to yourself (e.g., I’m a failure). When someone else’s behavior bothers you, you attach a negative label to that person (e.g., he is a jerk), rather than describing the behavior. Theological reflection: God loves us unconditionally and rejoices in us even when our behavior is not pleasing to him. For example, in the parable of the Prodigal Son (Luke 5:1–24), the father eagerly welcomes the son back home even though the son has squandered his inheritance and disgraced his family. This parable—a story meant to teach us about God’s relationship with humankind—demonstrates that the son’s identity and worth were not based on his behavior, but simply on being his father’s son. Likewise, our identity and worth are not based on what we do or don’t do, but simply on the fact that we are God’s children. 10. Personalization You see yourself as the cause of some negative external event for which you are not responsible. While we have some i­nfluence

194 | appendix c: reproducible resources

over people, what they do is ultimately their decision and responsibility, not ours. Theological reflection: God has control over the events that happen in the world. We, for the most part, do not. We should not presume to be God or try to fill his shoes, especially when negative events happen to us. There are many things we will not understand in this life and many things over which we have no control. In these situations, the scripture says we are to “be still, and know that I am God” (Psalm 46:10).

appendix c: reproducible resources | 195

Figure 5.2. ABCD(R)E Thought Monitor for Changing Your Mind: Metanoia Activating Event: Describe what was happening when the negative emotion(s) began. (Who? What? Where? When?)

Beliefs: What negative beliefs or expectations automatically went through your mind when you were in that situation? (What is your interpretation of what happened?) Specify the unhelpful thought category that best describes the error in the belief.

Consequence for Feelings and Behavior: What feelings resulted from these beliefs or expectations (e.g., sadness, guilt, anger)? Rate the intensity of each feeling using a scale of 1 to 10, where 10 is the most intense. What behavior did you engage in (or not engage in) as a result of these beliefs and feelings? (Did you behave in a way that is unhelpful or harmful to yourself or others?)

Dispute the Beliefs: What evidence do you have that your beliefs or expectations are not accurate, true, or helpful? What evidence do you have that you could manage the situation (based on your talents, past experience, support persons, or resources)?

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Religious Resources: How can your view of God, your Christian worldview, the Bible, religious writings, and other sources of spiritual wisdom provide evidence that challenge your automatic negative beliefs?

Effective New Belief and Consequence: What is a more accurate and helpful way of looking at the situation? Does this new belief change how you feel? Rate the intensity of each feeling again using a scale of 1 to 10, where 10 is the most intense.

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Figure 10.1. Giving Back: My Service Activity 1. Brainstorm a list of ways you could serve others. These might be things you have done in the past or have witnessed others doing. Be concrete and specific.

2. Rank each item on your list for level of difficulty on a scale of 1 to 10 with 10 being the most difficult for you to complete. Then choose one of the activities you ranked as being less difficult (rating between 1 and 5) to complete this week. The service activity I will complete is

The person(s) I will help is

When and where will the activity be completed? (Day, time, place, more than once?)

What do I need to complete the activity?

198 | appendix c: reproducible resources

What potential barriers and problems could get in the way of completing this activity?

How will I deal with these potential problems?

3. Set an intention for completing the activity. What makes you want to engage in this service activity? Does your faith play a role in your desire to serve others? If so, how?

4. Immediately before the activity: Rank your mood on a scale of 1 to 10, with 10 being the best mood you can imagine and 1 being the worst.

5. Immediately after the activity is completed: Rank your mood on a scale of 1 to 10. Was there a change in your mood? If yes, why do you think this is so?

Notes

Chapter 1—Why Integrate Religion into Therapy? 1. American Association of Pastoral Counselors and the Samaritan Institute Report. 2. Baetz et al. “Spirituality and Psychiatry in Canada”; Rose, “Spiritual Counseling.” 3. Morrow, Worthington, and McCullough, “Observers’ Perceptions of a Psychologist’s Treatment of a Religious Issue.” 4. McCullough and Worthington, “Observers’ Perceptions of a Counselor’s Treatment of a Religious Issue.” 5. Carlson et al., “Religion, Spirituality, and Marriage and Family Therapy.” 6. Rosmarin et al., “Attitudes toward Spirituality/Religion.” 7. Hathaway, Scott, and Garver, “Assessing Religious/Spiritual Functioning.” 8. Kosmin and Keysar, 2008 American Religious Identification Survey Summary Report. 9. Newport, “In U.S.” 10. Bonelli, Dew, et al., “Religious and Spiritual Factors in Depression.” 11. Koenig, King, and Carson, Handbook of Religion and Health. 12. Pirutinsky et al., “Does Negative Religious Coping Accompany?” 13. Johnson and Hayes, “Troubled Spirits.” 14. American Psychological Association, “Ethical Principles of Psychologists and Code of Conduct”; American Counseling Association, Code of Ethics and Standards of Practice. 15. American Psychological Association, “Guidelines for Providers of Psychological Services.” 16. National Association of Social Workers, “Code of Ethics,” sect. 1.05. 17. Anderson et al., “Faith-Adapted Psychological Therapies”; Azhar and Varma, “Religious Psychotherapy as Management of Bereavement”; Azhar, Varma, and Dharap, “Religious Psychotherapy in Anxiety Disorder Patients”; Berry, “Does Religious Psychotherapy Improve Anxiety?”; Hodge, “Spiritually Modified Cognitive Therapy”; Hook et al.,

200 | notes

“Empirically Supported Religious and Spiritual Therapies”; Koenig et al., “Religious vs. Conventional Cognitive-Behavioral Therapy”; McCullough, “Research on Religion-Accommodative Counseling”; Pargament, Psychology of Religion and Coping; Propst, “Comparative Efficacy of Religious and Nonreligious Imagery”; Propst, Ostrom, et al., “Comparative Efficacy of Religious and Nonreligious Cognitive-Behavior Therapy”; Razali, Hasanah, et al., “Religious-Sociocultural Psychotherapy”; Smith et al., “Outcomes of Religious and Spiritual Adaptations”; Tan and Johnson, ”Spiritually Oriented Cognitive-Behavioral Therapy”; Wade, Worthingon, and Vogel, “Effectiveness of Religiously Tailored Interventions”; Worthington and Sandage, “Religion and Spirituality”; Worthington et al., “Religion and Spirituality.” 18. Worthington et al., “Religion and Spirituality.” 19. Propst, “Comparative Efficacy of Religious and Nonreligious Imagery”; Propst, Ostrom, et al., “Comparative Efficacy of Religious and Nonreligious Cognitive-Behavior Therapy.” 20. Hawkins et al., “Secular versus Christian Inpatient Cognitive-Behavioral Therapy Programs”; Pecheur and Edwards, “Comparison of Secular and Religious Versions of Cognitive Therapy.” 21. Pecheur and Edwards, “Comparison of Secular and Religious Versions of Cognitive Therapy.” 22. Koenig, et. al., “Religious vs. Conventional Cognitive-Behavioral therapy.” 23. Koenig et al., “Religious Involvement Is Associated with Greater Purpose;” Pearce et al, “Religious vs. Effects of Conventional Cognitive-Behavioral Therapy on Generosity;” Pearce et al., “Effects of Religious vs. Conventional Cognitive-Behavioral Therapy in Gratitude.” 24. Hodge, “Spiritually Modified Cognitive Therapy”; Hook et al., “Empirically Supported Religious and Spiritual Therapies.” 25. Keating and Fretz, “Christians’ Anticipations about Counselors.” 26. American Association of Pastoral Counselors and the Samaritan Institute Report; Weaver, “Has There Been a Failure?” 27. Molock et al., “Developing Suicide Prevention Programs.” 28. Wang et al., “Patterns and Correlates of Contacting Clergy.” 29. Nieuwsma et al., “Collaborating across the Departments of Veterans Affairs and Defense.” 30. Vogel et al., “Examining Religion and Spirituality as Diversity Training.” 31. Rosmarin et al., “Attitudes toward Spirituality/Religion.” 32. Morrison et al., “Perceptions of Clients and Counseling Professionals.” 33. Delaney, Miller, and Bisono, “Religiosity and Spirituality among Psychologists”; Rosmarin et al., “Attitudes toward Spirituality/Religion.” 34. Rosmarin et al., “Attitudes toward Spirituality/Religion.”

notes | 201

35. Delaney, Miller, and Bisono, “Religiosity and Spirituality among Psychologists.” 36. Hathaway, Scott, and Garver, “Assessing Religious/Spiritual Functioning.” 37. Rosmarin et al., “Attitudes toward Spirituality/Religion.” 38. Propst et al., “Comparative Efficacy of Religious and Nonreligious Cognitive-Behavior Therapy.” 39. Wade et al., “Effectiveness of Religiously Tailored Interventions.” 40. Tan, S. Y., and W. B. Johnson. “Spiritually Oriented Cognitive-Behavioral Therapy.”

Chapter 2—Assessment 1. Pargament, Spiritually Integrated Psychotherapy. 2. Ciarrocchi et al., Religious Cognitive Behavioral Therapy. 3. Richards and Bergin, Spiritual Strategy for Counseling and Psychotherapy. 4. Hill and Hood, Measures of Religiosity. 5. Hood, Hill, and Spilka, Psychology of Religion. 6. Beck, Ward, et al., “Inventory for Measuring Depression.” 7. Zigmond and Snaith, “Hospital Anxiety and Depression Scale.” 8. Radloff, “CES-D Scale.” 9. Breuninger et al., “Psychologists and Clergy Working Together.” 10. Koenig et al., “Religious Involvement Is Associated with Greater Purpose;” Pearce et al, “Religious vs. Effects of Conventional Cognitive-Behavioral Therapy on Generosity;” Pearce et al., “Effects of Religious vs. Conventional Cognitive-Behavioral Therapy in Gratitude.” 11. Richards and Bergin, Spiritual Strategy for Counseling and Psychotherapy. 12. Behnke, “Informed Consent.” 13. American Psychological Association, “Ethical Principles of Psychologists and Code of Conduct.” 14. Plante, “Addressing Problematic Spirituality in Therapy”; Breuninger et al., “Psychologists and Clergy Working Together.” 15. Plante, “Addressing Problematic Spirituality in Therapy” 16. Nieuwsma et al., “Collaborating across the Departments of Veterans Affairs and Defense.”

Chapter 3—Introducing the CCBT Treatment Model to your Client 1. 2. 3. 4. 5.

Paquette et al., ”Change the Mind.” Beauregard, “Mind Does Really Matter.” Arnone et al., “Magnetic Resonance Imaging Studies.” Barsaglini et al., “Effects of Psychotherapy on Brain Function.” Goldapple et al., “Modulation of Cortical-Limbic Pathways”; Kennedy et al., “Differences in Brain Glucose Metabolism.”

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6. Beauregard, “Mind Does Really Matter.” 7. Kandel, “New Intellectual Framework for Psychiatry.” 8. Beck et al., Cognitive Therapy of Depression. 9. Chambless and Ollendick, “Empirically Supported Psychological Interventions.” 10. Smith et al., “Outcomes of Religious and Spiritual Adaptations in Psychotherapy.”

Chapter 4—Renewing Your Mind: Planting Truth 1. 2. 3. 4. 5.

Mechelli, “Psychoanalysis on the Couch.” Holzel et al., “Investigation of Mindfulness Meditation Practitioners.” Goyal et al., “Meditation Programs.” Wachholtz and Pargament, “Migraines and Meditation.” Carlson et al., “Controlled Evaluation of Devotional Meditation and Progressive Relaxation.” 6. Masters and Spielmans, “Prayer and Health”; Koenig et al., Handbook of Religion and Health. 7. Goyal et al., “Meditation Programs.”

Chapter 5—Changing Your Mind: Metanoia 1. Lazarus and Folkman, Stress, Appraisal, and Coping. 2. Beck et al., Cognitive Therapy of Depression; Beck, Cognitive Therapy for Challenging Problems. 3. Tindle et al., “Optimism.” 4. Pearce and Koenig, “Cognitive Behavioral Therapy for the Treatment of Depression.” 5. Koenig et al., Handbook of Religion and Health. 6. Tan and Johnson, “Spiritually Oriented Cognitive-Behavioral Therapy.” 7. Kruis, Quick Scripture Reference for Counseling; Vasegh, “Cognitive Therapy of Religious Depressed Patients.” 8. Ellis, Reason and Emotion in Psychotherapy.

Chapter 6—Finding God and the Blessing in Suffering: Redemptive Reframing 1. Tedeschi and Calhoun, “Posttraumatic Growth”; Tedeschi and Calhoun, “Beyond the Concept of Recovery.” 2. Gamino, Sewell, and Easterling, “Scott and White Grief Study–Phase 2.” 3. Neimeyer, “Searching for the Meaning of Meaning.” 4. Calhoun, Tedeschi, Cann, and Hanks, “Positive Outcomes Following Bereavement.” 5. Holland and Neimeyer, “Examination of Stage Theory of Grief.” 6. Mols et al., “Well-Being”; Lichtenthal and Cruess, “Effects of Directed Written Disclosure.”

notes | 203

7. Pargament, Psychology of Religion and Coping; Wortmann and Park, “Religion/Spirituality and Change in Meaning.” 8. Jang and Lamendola, “Social Work in Natural Disasters.” 9. Chen, “Written Emotional Disclosure”; Chen and Contrada, “Framing Written Emotional Expression.” 10. Shear, Dennard, et al., “Developing a Two-Session Intervention.” 11. Pearce, Coan, et al., “Unmet Spiritual Care Needs”; Pargament, Smith, et al., “Patterns of Positive and Negative Religious Coping.” 12. Pargament, Koenig, et al., “Religous Struggle as a Predictor of Mortality.” 13. Wortmann and Park, “Religion/Spirituality and Change in Meaning.”

Chapter 7—Reaching Out and Connecting 1. Krohne and Slangen, “Influence of Social Support”; Rutledge et al., “Social Networks and Marital Status.” 2. Taylor, “Social Support.” 3. Rietschlin, “Voluntary Association Membership.” 4. Smith et al., “Mental Activation of Supportive Ties.” 5. Cohen et al., “Social Skills and the Stress-Protective Role of Social Support.” 6. Pargament, Psychology of Religion and Coping. 7. Cohen, Underwood, and Gottlieb, Social Support Measurement and Intervention; Koenig et al., Handbook of Religion and Health. 8. McCullough, Hoyt, et al., “Religious Involvement and Mortality.” 9. Krause, “Exploring the Stress-Buffering Effects.” 10. Krause, “Exploring the Stress-Buffering Effects”; Krause and Hayward, “Church-Based Social Support.” 11. Krause, Ellison, and Wulff, “Church-Based Emotional Support.” 12. Otto and Smits, Exercise for Mood and Anxiety. 13. Hill and Pargament, “Advances in the Conceptualization and Measurement of Religion and Spirituality”; Seligman et al., “Positive Psychology Progress.”

Chapter 8—Letting Go and Letting God: Acceptance and Forgiveness 1. Lawler-Row et al., “Forgiveness, Physiological Reactivity, and Health.” 2. Hayes et al., Acceptance and Change. 3. Sanderson and Linehan, “Acceptance and Forgiveness.” 4. Linehan, Skills Training Manual. 5. Hayes et al., Acceptance and Change. 6. Sanderson and Linehan, “Acceptance and Forgiveness.” 7. Pargament, Psychology of Religion and Coping. 8. Koenig, Pargament, and Nielsen, “Religious Coping in Medically Ill Hospitalized Older Adults.”

204 | notes

9. Toussaint and Friedman, “Forgiveness, Gratitude, and Well-Being”; Worthington and Wade, “Psychology of Unforgiveness.” 10. Wade, Hoyt, Kidwell, and Worthington, “Efficacy of Psychotherapeutic Interventions.” 11. Toussaint and Friedman, “Forgiveness, Gratitude, and Well-Being.” 12. Sanderson and Linehan, “Acceptance and Forgiveness.” 13. For a review, see Wade, Hoyt, Kidwell, and Worthington, “Efficacy of Psychotherapeutic Interventions.” 14. Wade, Hoyt, Kidwell, and Worthington, “Efficacy of Psychotherapeutic Interventions.” 15. Rye and Pargament, “Forgiveness and Romantic Relationships in College.” 16. Seedall, Butler, and Elledge, “Does Religious Motivation Influence the Conceptualization and Acceptability of Forgiveness?” 17. Lewis, Weight of Glory, 182. 18. Cole and Pargament, “Spiritual Surrender.” 19. Shapiro, “Who Wrote the Serenity Prayer?” 20. Worthington, Forgiving and Reconciling. 21. Enright and Fitzgibbons, Helping Clients Forgive. 22. Ciarrocchi et al., Religious Cognitive Behavioral Therapy.

Chapter 9—Saying Thanks: Gratitude 1. Beck et al., Cognitive Therapy of Depression. 2. Emmons and McCullough, “Counting Blessings versus Burdens”; McCullough, Emmons, and Tsang, “Grateful Disposition”; Watkins et al., “Gratitude and Happiness”; Nelson, “Appreciating Gratitude.” 3. Kashdan, Uswatte, and Julian, “Gratitude and Hedonic and Eudaimonic Well-Being”; Coffman, Personality. 4. Emmons and McCullough, “Counting Blessings versus Burdens”; Seligman et al., “Positive Psychology Progress”; Seligman et al., “Positive Psychotherapy”; Watkins et al., “Gratitude and Happiness”. 5. Emmons and Kneezel, “Giving Thanks”; Griffith, “Joy Unspeakable and Full of Glory”; McCullough et al., “Grateful Disposition.” 6. Perez et al., “Types of Prayer.” 7. Rosmarin et al., “Grateful to God or Just Plain Grateful?” 8. Pearce et al., “Effects of Religious vs. Conventional Cognitive-Behavioral Therapy on Gratitude.” 9. Pearce et al., “Effects of Religious vs. Conventional Cognitive-Behavioral Therapy on Gratefulness.” 10. Rosmarin et al., “Grateful to God or Just Plain Grateful?” 11. Ciarrocchi et al., Religious Cognitive Behavioral Therapy. 12. Ciarrocchi et al., Religious Cognitive Behavioral Therapy.

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Chapter 10—Giving Back: Service 1. Schwartz et al., “Altruistic Social Interest Behaviors.” 2. Baumeister, Meanings of Life; Miller et al., “Social Interest and Feelings of Hopelessness”; Schwartz and Sendor, “Helping Others Helps Oneself ”; Zarski et al., Tasks of Life Survey. 3. Brown et al., “Providing Support”; Krause, “Exploring the Stress-Buffering Effects.” 4. Carter, “Neuroendocrine Perspectives.” 5. Lam, “Religion and Civic Culture”; Koenig et al., “Religiousness”; Saroglou et al., “Prosocial Behavior and Religion.” 6. McCullough and Willoughby, “Religion, Self-Regulation, and Self-Control.” 7. Pearce et al, “Religious vs. Effects of Conventional Cognitive-Behavioral Therapy on Generosity.”

Appendix A 1. Wade et al., “Effectiveness of Religiously Tailored Interventions in Christian Therapy.” 2. Propst et al., “Comparative Efficacy of Religious and Nonreligious Cognitive-Behavior Therapy.” 3. Worthington et al., “Religion and Spirituality.”

A ppendix B 1. Underwood and Teresi, “Daily Spiritual Experiences Scale.” 2. Fetzer, Multidimensional Measurement. 3. Hoge, “Validated Intrinsic Religious Motivation Scale.” 4. Pargament et al., “Patterns of Postive and Negative Religious Coping.” 5. Kass et al., “Health Outcomes and a New Index of Spiritual Experience.” 6. Ellison, “Spiritual Well-Being.”

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About the Author

Michelle Pearce, PhD, is an assistant professor and clinical psychologist at the Center for Integrative Medicine at the University of Maryland, Baltimore School of Medicine. She is also the director of the Death, Dying, and Mourning: Applied Thanatology online graduate certificate program. Dr. Pearce’s research seeks to answer the questions of how to best integrate religion/spirituality into the practice of psychotherapy, improve bereavement resilience, and meet the spiritual needs among people with cancer at the end of life. She is passionate about applying clinical research to improve patient care, well-being, and quality of life. Dr. Pearce received her PhD from Yale University, after completing an internship in medical psychology at Duke University Medical Center. She then completed two postdoctoral fellowships at Duke University Medical Center, one in CBT and one with the Center for Spirituality, Theology, and Health. She also received advanced training in integrative medicine from the Center for Mind-Body Medicine. Dr. Pearce has published over forty peer-reviewed articles and book chapters, has given numerous local and national speeches, and has received several honors in her field. These honors include an early career psychologist credentialing scholarship awarded by the National Register of Health Service Providers in Psychology; the

220 | about the author

Jack Shand Research Award granted by the Society for the Scientific Study of Religion for excellence in graduate research on the empirical study of religion; several awards from Yale University for distinguished academic achievement; and a Social Science and Humanities Research Council doctoral fellowship granted by the federal government of Canada.

Index

AAPC. See American Association of Pastoral Counselors abandonment depression and faith, treatment, 10 by God, 7 ABC. See Activating event, Beliefs, and Consequence ABCD(R)E method, of thought identification and challenge, 65 ABC stage, 71–72 D(R)E stage, 73–74 thought monitor for, 72–73, 74–75, 127 ACA. See American Counseling Association acceptance. See also letting go and letting God Acceptance and Commitment Therapy, 117 through active spiritual surrender, 121–22 defined, 117 Dialectical Behavior Therapy and, 117 scripture for, 119 Acceptance and Commitment Therapy, 117 Activating event, Beliefs, and Consequence (ABC) stage, of CCBT, 71–72 active listening, 86–87

active spiritual surrender guidelines, 121–22 activity choice, in service activity exercise, 159 activity monitor, 104–5 activity planning, in service activity exercise, 159 African Americans clergy support, 10 mental health treatment, 10 all-or-nothing distorted thinking style, 67 altruism, CCBT positive outcomes for, 9 American Association of Pastoral Counselors (AAPC), 11 American Counseling Association (ACA), 7 American Psychiatric Association, CCBT depression treatment criteria of, 9 American Psychological Association (APA) Board of Ethnic and Minority Affairs, 7 Ethics Code Standard, 26 on religion diversity clinical competence, 7 anxiety HADS measure for, 25 spiritually integrated therapies for, 8

222 | index

APA. See American Psychological Association assessment avoiding assumptions, 19–21 of depression, 24–25 informed consent, 25–26 religious beliefs as problem, 29–31 of religious involvement, 24 religious involvement questionnaires, 24 religious/spiritual history, 21–24 religious/spiritual history questions, 22–23 self-reflection, 26–29 of service activity exercise impact, 160 of service behaviors, 155–56 Association of Behavioral and Cognitive Therapists on religion and spirituality discussion, 4 on religious issues relevance, 4 assumptions avoidance, in assessments, 19–21 automatic thoughts, in CBT, 14 battle in mind scripture, 63, 65 scriptures imagery of, 63–64 BDI. See Beck Depression Inventory Beck, Aaron, 35 Beck Depression Inventory (BDI), 25 behavior, thoughts influence on, 33–34 behavior pattern modification, 15 benefits finding, in redemptive reframing, 86, 90–91, 92 psychotherapy addressing of faith, 5 of spiritual and biblical language use, 25

Bible practitioners use of, 37 redemptive reframing in, 85–86 stories on suffering, 84–85, 90–91 as truth, 49 Board of Ethnic and Minority Affairs, of APA, 7 body, thoughts influence on, 3 3–34 brain during CBT, 34 images after MBSR, 47 neuroplasticity of, 33–34 prayer influence on, 48 prefrontal cortex activation, 34 thoughts influence on, 33–34 burden, scripture on bearing one another’s, 103 case example, 16 for changing your mind: metanoia CCBT tool, 61–62 for finding God and blessing in suffering: redemptive reframing CCBT tool, 81–82 for giving back: service CCBT tool, 151–52 for letting go and letting God: acceptance and forgiveness CCBT tool, 115–17 for reaching out and connecting CCBT tool, 99–101 for renewing of mind: planting truth CCBT tool, 45–47 for saying thanks: gratitude CCBT tool, 135–63 catastrophizing distorted thinking style, 68–69 caution, on giving back: service, 158 CBT. See cognitive behavioral therapy CCBT. See Christian cognitive behavioral therapy Center for Epidemiological Studies-Depression (CES-D), 25

index | 223

CES-D. See Center for Epidemiological Studies-Depression changing your mind: metanoia CCBT tool, 16, 79, 170 ABCD(R)E method, 65, 71–75 ABCD(R)E thought monitor, 72–73, 74–75, 127 case example, 61–62 Christianity and, 39–40, 63–64 clinical application, 75–78 distorted thinking styles identification, 66–71 scientific support for, 62–63 scriptures for, 39–40, 61, 63–64, 73, 74–75 skill-building activities, 65–75 therapist introduction to, 65–66, 73–74 Christian cognitive behavioral therapy (CCBT) ABCD(R)E approach, 65, 71–75, 127 altruism outcomes, 9 American Psychiatric Association treatment criteria, 9 CBT outcomes compared to, 9 CBT training for, 37 clergy consultation, 174–75 client introduction to, 38–40 as client-centered approach, 169 clinical competence, 14 effectiveness of, 9 gratitude outcomes, 9 home practice activities, 40–41 hope and, 173 life purpose outcomes, 9 next steps, 173 practitioner competencies for, 37 relapse prevention, 169–76 treatment mode, 37–38 Christian cognitive behavioral therapy tools changing your mind: metanoia, 16, 61–79, 170 finding God and blessing in suffering: redemptive reframing, 17, 81–97, 170

giving back: service, 17, 151–67, 170 letting go and letting God: acceptance and forgiveness, 17, 115–33, 170 reaching out and connecting, 17, 99–114, 170 renewing of mind: planting truth, 16, 45–59, 170 saying thanks: gratitude, 17, 135–49, 170 summary of, 170 Christian cognitive behavioral therapy treatment model, 33–41 thoughts effect on brain, body, behavior, 33–34 Christianity CBT commonalities with, 35–37 CBT roots in, 35–36 changing your mind: metanoia and, 39–40, 63–64 finding God and blessing in suffering: redemptive reframing and, 84–86 giving back: service and, 154 letting go and letting God: acceptance and forgiveness and, 119–20 reaching out and connecting and, 102–3 renewing of mind: planting truth and, 49–50 saying thanks: gratitude and, 138–39 therapists bias, 28 triune being of God belief, 49 U.S. percentage of, 6 Christians abandonment of faith and treatment, 10 depression guilt and shame, 10 faith erosion of fear, 10 clergy African Americans support from, 10

224 | index

clergy (continued) CCBT consultation of, 174–75 Hispanics support from, 10 informed consent and, 26 mental health disorders diagnosis and treatment, 10 for negatively based religious beliefs, 30 referral to, 9–12 release forms for referral and consultation, 30 client CCBT introduction to, 38–40 feedback, in CBT, 15 informed consent on treatment understanding, 26 positive change for, 3 therapist similar religious beliefs with, 13–14 therapist spiritual issues discussion, 4 client-centered therapy CCBT as, 23 metanoia and, 65 in redemptive reframing, 86 clinical application for changing your mind: metanoia CCBT tool, 75–78 for finding God and blessing in suffering: redemptive reframing CCBT tool, 88–89, 93–96 for giving back: service CCBT tool, 160–65 for letting go and letting God: acceptance and forgiveness CCBT tool, 122–29, 129–33 for reaching out and connecting CCBT tool, 109–13 for renewing of mind: planting truth CBBT tool, 56–59 for saying thanks: gratitude CCBT tool, 145–49 clinical competence, 4, 37 APA and ACA on religion diversity, 7 clinical practice, spirituality relevance to, 4

clinical training on CBT, 37 on lack of religious and spiritual issues, 12 cognitive behavioral therapy (CBT) ABCDE approach, 65 automatic thoughts, 14 brain during, 34 CCBT outcomes compared to, 9 Christianity commonalities, 35–37 Christianity roots, 35–36 core beliefs examination, 14, 15 model components, 14–15 practitioners training on, 37 cognitive restructuring, 65 gratitude and, 142–43 confession of sins scripture, 120 contemplative prayer, 53 instructions for, 55–56 scriptures for, 54, 55 core beliefs, in CBT, 14, 15 cultural competence, ethical codes on, 7 depression abandonment of faith and, 10 assessment of, 24–25 Christian guilt and shame for, 10 JAMA on meditation reduction of, 47–48 negative and self-blaming interpretations, 63 negative self-talk, 63 practitioners diagnosis of, 37 religion relationship with, 6 religious beliefs and practices talk for reduction in, 8–9 scriptures contribution to, 64 spiritual crises and, 83 spiritual meditation reduction of, 48 spiritual or biblical language use, 25 spiritually integrated therapies reduction of, 8

index | 225

U.S. prevalence, 5 depression measures BDI, 25 CES-D, 25 HADS, 25 numerical mood rating scale, 25 Diagnostic and Statistical Manual of Mental Disorders (DSM), 11 Dialectical Behavior Therapy, acceptance and, 117 Disputing beliefs, Religious resources, and Effective new belief and consequences (D(R) E) stage, of CCBT, 73–74 disqualifying the positive distorted thinking style, 68 distorted thinking styles, 66 all-or-nothing thinking, 67 catastrophizing, 68–69 disqualifying the positive, 68 emotional reasoning, 69 fortune telling error, 68 labeling, 70 mental filter, 67 overgeneralization, 67 personalization, 70 scriptures for, 67–70 should statements, 69 theological reflections on, 67–71 D(R)E. See Disputing beliefs, Religious resources, and Effective new belief and consequences DSM. See Diagnostic and Statistical Manual of Mental Disorders Ellis, Albert, 65 emotional component, of forgiveness, 118 emotional health, religious belief related to, 4 emotional reasoning distorted thinking style, 69 emotional stress, reduction of, 8 ethical codes, on cultural competence, 7 Ethics Code Standard, APA, 26

faith Christians’ abandonment of, 10 Christians’ erosion of fear, 10 psychotherapy benefits of addressing, 5 religious rationale of walking by, 105–6 faith community. See also reaching out and connecting increasing involvement with, 106–9 scriptures on assembly of, 99, 102–3 social support from, 6, 101–2 faith-related struggles, 6–7 finding God and blessing in suffering: redemptive reframing CCBT tool, 17, 97, 170 Bible stories on suffering, 84–85, 90–91 case example, 81–82 Christianity and, 84–86 clinical application, 88–89, 93–96 meaning making and benefit finding step, 86, 90–91, 92 posttraumatic growth, 82–83, 91–92 redemptive reframing, in Bible, 85–86 scientific support for, 82–84 skill-building activities, 86–88 spiritual struggles and sacred losses discussion, 86–88 “Footprints in the Sand” (Stevenson), 92 forgiveness. See also letting go and letting God decisional component of, 118 defined, 118 emotional component of, 118 interventions for, 118 prayers for, 128–29 process model for, 125 REACH model, 125 religion association with, 118 repentance and, 125–29 scriptures on, 115, 120

226 | index

forgiveness (continued) steps for, 125–28 fortune telling error distorted thinking style, 68 giving back: service CCBT tool, 17, 170 case example, 151–52 caution on, 158 Christianity and, 154 clinical application, 160–65 motivation for service, 156–58 scientific support for, 152–54 service activity exercise, 158–60 service activity worksheet, 165–67 service behaviors assessment, 155–56 serving and mood relationship, 155 skill-building activities, 155–60 therapists introduction to, 155 God. See also finding God and blessing in suffering; letting go and letting God abandonment by, 7 gratitude for rewards of, 137–38 loving of, 154 scripture portrayal of, 119 triune being of, 49 Golden Rule, 153 gratitude. See also saying thanks CCBT positive outcomes for, 9 as CCBT tool, 17, 135–49 to God rewards, 137–38 moral and spiritual mandate for, 138 as negative life events coping strategy, 137 scriptures on, 135, 138–39, 140 thanks for everything instructions, 138–39 guarding of heart scriptures, 49, 50 guilt, of Christians, 10 HADS. See Hospital Depression and Anxiety Scale

health religious belief related to emotional, 4 serving others and, 152 Hispanics clergy support, 10 mental health treatment and, 10 Holy Spirit scriptures, 49 home practice activities, CCBT, 40 hope scriptures, 173 Hospital Depression and Anxiety Scale (HADS), 25 informed consent, 25 clergy consultation and referral, 26 client’s treatment understanding, 26 key components of, 27 licensure boards requirement, 26 intention setting, in service activity exercise, 159–60 interventions, for forgiveness, 118 Jesus, as truth, 49 Journal of the American Medical Association (JAMA), 47–48 labeling distorted thinking style, 70 language, for relapse prevention, 171 letting go and letting God: acceptance and forgiveness CCBT tool, 17, 170 case example, 115–17 Christianity and, 119–20 clinical application, 122–29, 129–33 repentance and forgiveness, 125–29 scientific support for, 117–18 skill-building activities, 120–22 licensure board informed consents requirements, 26 of pastoral counselors, 11

index | 227

of practitioners, 37 life CCBT positive outcomes for purpose of, 9 expectancy, serving others and, 152–53 gratitude and negative events of, 137 MBSR. See Mindfulness-Based Stress Reduction meaning making, 83, 86, 92 in redemptive reframing, 90–91 Measures of Religiosity, 24 meditation JAMA on depression reduction from, 47–48 on truth, 49 memorization of scripture activity, 51–53 mental filter distorted thinking style, 67 mental health disorders clergy on diagnosis and treatment of, 10 licensed pastoral counselors training in, 11 mental health professionals mental health disorders diagnosis and treatment, 11 reduced religious practices, 12–13 mental health services for African Americans and Hispanics, 10 religion and, 9–10 metanoia. See changing your mind mind. See also changing your mind; renewing of mind; thoughts as battlefield scriptures, 63, 65 renewing of mind scriptures, 45, 51 scriptures on changing of, 39–40, 61, 63–64, 73, 74–75 truth religious belief and, 49 Mindfulness-Based Stress Reduction (MBSR), 47

mood, serving relationship with, 155 mood rating scale, for depression, 25 mortality, religious attendance and, 102 motivation, for service, 156–58 negative life events, gratitude as coping strategy for, 137 negative self-talk, depression and, 63 negatively based religious beliefs, 29–30 neuroplasticity, 33–34 numerical mood rating scale, for depression, 25 overgeneralization distorted thinking style, 67 pastoral counselors, licensed AAPC certification, 11 mental health and religion training, 11 personalization distorted thinking style, 70 positive change, for client, 3 posttraumatic growth, 82–83, 91–92 practitioners. See also mental health professionals; therapists biblical texts and stories helpful for, 37 CBT training for, 37 depression diagnosis by, 37 state and national licensure, 37 prayer brain influenced by, 48 contemplative, 53–56 Serenity Prayer, 122 of thanksgiving, 143–45 prefrontal cortex, CBT activation of, 34 psychological outcomes, of spiritually integrated therapy, 8–9

228 | index

rationale, for reaching out and connecting, 103–4 REACH model, of Worthington, 125 reaching out and connecting CCBT tool, 17, 114, 170 activity monitor, 104–5 case example, 99–101 Christianity and, 102–3 clinical application, 109–13 faith community increasing involvement, 106–9 rationale for, 103–4 scientific support for, 101–2 scriptures for, 109 skill-building activities, 103–9 therapist introduction to, 107, 108 walking by faith religious rationale, 105–6 redemptive reframing. See also finding God and blessing in suffering benefits finding in, 86, 90–91, 92 in Bible stories, 85–86 client-centered therapy in, 86 meaning making in, 90–91 scriptures on, 85–86, 92 relapse prevention CCBT tools use, 171–72 concrete language for, 171 release forms, for clergy referral and contact, 30 religion depression relationship with, 6 diversity, APA and ACA on, 7 forgiveness association with, 118 gratitude expression and, 137 licensed pastoral counselors training in, 11 mental health services participation, 9–10 in psychotherapy, 3–5 therapists integration and competence link, 4 U.S. affiliation with, 5–6 religious beliefs assessment of problem, 29–31

client and therapist similarity of, 13–14 depression reduction by talking about, 8–9 emotional health related to, 4 emotional stress reduction from talking about, 8 meditating on truth, 49 negatively based, 29–30 Satan belief, 49 triune being of God, 49 religious community. See faith community religious identity, 3–4 religious participation assessment of, 24 mortality and, 102 religious practices depression reduction by talking about, 8–9 mental health professionals reduced, 12–13 religious rationale, of walking by faith, 105–6 religious worldview, 3–4 religious/spiritual history, in assessments, 24 Pargament on, 21 suggested questions, 22–23 renewing of mind: planting truth CCBT tool, 16, 170 case example, 45–47 Christianity and, 49–50 clinical application, 56–59 contemplative prayer for, 53–56 inspirational passage and scripture memorization, 51–53 religious beliefs and, 49–50 scientific support for, 47–48 scriptures on, 45, 51 skill-building activities, 50–56 therapist introduction to, 50–51 repentance, forgiveness and, 125–29 sacred losses, spiritual struggles and, 86–88

index | 229

Satan, 49 saying thanks: gratitude CCBT tool, 17, 170 case example, 135–63 Christianity and, 138–39 clinical application, 145–49 cognitive restructuring, 142–43 gratitude list, 141–42 letter, 143–45 prayers of thanksgiving, 143–45 reason for, 136 scientific support for, 137–38 skill-building activities, 139–45 therapist introduction to, 140–41 scientific support for changing your mind: metanoia, 62–63 for finding God and blessing in suffering: redemptive reframing, 82–84 for giving back: service, 152–54 for letting go and letting God: acceptance and forgiveness, 117–18 for reaching out and connecting, 101–2 for renewing of mind: planting truth, 47–48 for saying thanks: gratitude, 137–38 scriptures battle imagery, 63–64 on bearing one another’s burdens, 103 on Bible as truth, 49 changing of mind and, 39–40, 61, 63–64, 73, 74–75 on community assembling, 99, 102–3 on confession of sins, 120 for connecting, 109 for contemplative prayer, 54, 55 depression contribution from, 64 for distorted thinking styles, 67–70 on forgiveness, 115, 120 on gratitude, 135, 138–39, 140

on gratitude toward God, 138 on guarding of heart, 49, 50 on Holy Spirit, 49 on hope, 173 inaccurate interpretation of, 64 on Jesus as truth, 49 location of, 53 on loving God and neighbor, 154 memorization activity, 51–53 on mind as battlefield, 63, 65 on pain and suffering, 85, 91 portrayal of God, 119 on portrayal of God, 119 on prayers of thanksgiving, 143 on redemptive reframing, 85–86, 92 on renewing of mind, 45, 51 on service, 151, 154, 157, 160 sinful nature and, 119–20 on suffering, 81, 84–85, 90, 91 on sword, 63–64 on thoughts, 63–64 on thoughts, feelings, behaviors relationship, 35, 39–40 on truth, 51 self-reflection, by therapists, 175–76 assessment of, 26–29 Serenity Prayer (Niebuhr), 122 service. See also giving back life expectancy and, 152–53 mood relationship with, 155 scriptures on, 151, 154, 157, 160 service activity exercise, 158 assessment on activity impact, 160 choice of activity, 159 intention setting, 159–60 planning activity, 159 worksheet, 165–67 service behaviors assessment, 155–56 shame of Christians, for depression, 10 should statements distorted thinking style, 69 sins, 119–20

230 | index

skill-building activities for changing your mind: metanoia CCBT tool, 65–75 for finding God and blessing in suffering: redemptive reframing CCBT tool, 86–88 for giving back: service CCBT tool, 155–60 for letting go and letting God: acceptance and forgiveness CCBT tool, 120–22 for reaching out and connecting CCBT tool, 103–9 for renewing of mind: planting truth CCBT tool, 50–56 for saying thanks: gratitude CCBT tool, 139–45 social support, from faith community, 6, 101–2 Socratic questioning, 15, 65 spiritual and biblical language, benefits of use, 25 spiritual crises, depression and, 83 spiritual distress, in U.S., 7 spiritual issues, client discussion with therapist, 4 spiritual meditation, depression reduction from, 48 spiritual struggles abandonment by God, 7 discussion about, 86–87 sacred losses and, 86–88 spirituality, clinical practice relevance to, 4 spiritually integrated therapies anxiety reduction, 8 depression reduction, 8 spiritual and biblical language use in, 25 Worthington on, 8 Stress and Coping Theory, of Lazarus and Folkman, 62 suffering. See also finding God and blessing in suffering Bible stories on, 84–85, 90–91 scriptures on, 81, 84–85, 90, 91 sword, scriptures on, 63–64

thanksgiving, prayer of, 143–45. See also saying thanks theological reflections, on distorted thinking styles, 67–71 therapeutic alliance, 3 therapists. See also practitioners Christian bias, 28 client similar religious beliefs with, 13–14 religion integration and competence link, 4 self-reflection by, 26–29, 175–76 spirituality relevance to clinical practice, 4 unconscious belief and experiences activation, 28 therapists dialogue introduction to CCBT treatment, 38–40 to changing your mind: metanoia, 65–66, 73–74 to contemplative prayer, 55 contemplative prayer instructions, 55–56 to gratitude, 140–41 to gratitude letter activity, 144 to passage memorization, 51–52 for reaching out and connecting, 107, 108 to renewing of mind, 50–51 to spiritual struggles and sacred losses, 87, 90 thoughts ABCD(R)E thought monitor, 72–73, 74–75, 127 automatic, in CBT, 14 brain, body, behavior relationship with, 33–34 feelings, behaviors relationship scriptures, 35, 39–40 scriptures on, 63–64 treatment engagement, 3 triune being of God belief, 49 trust and acceptance scriptures, 119 truth. See also renewing of mind: planting truth Bible as, 49 Jesus as, 49

index | 231

meditating on, 49 renewal of mind religious belief, 49 scriptures on, 51 unconscious beliefs, of therapists, 28 United States (U.S.) Christianity percentage in, 6

depression prevalence in, 5 religion affiliation in, 5–6 spiritual distress in, 7 walking by faith religious rationale, 105–6 REACH model of, 125 on spiritually integrated therapies, 8