Spiritual Changes-2 Spiritual Changes as Psychotherapy Outcomes

Interest in spiritual interventions in psychotherapy has increased dramatically in recent years as indicated by publication of at least 14 books on this topic in the past eight years, and by the offering of continuing education workshops on religious issues in psychotherapy at APA. Research and/or theorizing has begun on: religious values in psychotherapy, religious interventions (process), religiosity and mental health, graduate training in religious/spiritual interventions, and religious assessment. However, a review of the literature suggests that so far investigation of religious/spiritual outcomes of psychotherapy has been neglected, although examining such outcomes seems an obvious corollary of making the interventions. Results of two studies which show significant gains on Spiritual Well-Being following brief therapy are reported. Although causality cannot be firmly established, these results provide support for the hypotheses that psychotherapy produces favorable spiritual outcomes, and that spiritual benefits occur whether or not spiritual interventions are explicitly and consciously included. Spiritual Changes 3 Spiritual Changes as Psychotherapy Outcomes Rodger K. Bufford, T. Wilson Renfroe, and George Howard Graduate School of Clinical Psychology George Fox College In the past fifteen years, considerable interest has developed in the relationship of religion to mental health. First, in 1980 Bergin began a discussion of the role of religious values in psychotherapy (e.g., Bergin, 1980a, b, 1991; Kelly & Strupp, 1992; Martinez, 1991; Walls, 1980; Worthington, 1993); here the emphasis was on treatment goals. Second, a growing interest has emerged regarding ethical concerns and practical strategies for addressing religions issues in psychotherapy. Several significant texts (e.g., Benner, 1987, 1988; Lovinger, 1984, 1994; Propst, 1988; Spero, 1985; Stern, 1985), and numerous articles (e.g., Bergin, 1991; DiBlasio & Benda, 1991; Propst, Ostrum, Watkins, Dean, & Mashburn, 1992; Worthington & DiBlasio, 1990 ) have appeared which are devoted to this topic. Third, preliminary discussion and investigation has begun of interventions which may be spiritual in nature but are used widely among therapists, such as forgiveness (Enright & Zell, 1989), and remorse (Schneiderman, 1989; Stern, 1989). Fourth, there has been initial study of interventions which are employed largely by religious therapists with religious clients, such as the use of religious imagery (Propst, 1980), and religious cognitive-behavioral interventions (Propst, Ostrum, Watkins, Dean, & Mashburn, 1992). Fifth, there has been preliminary investigation of the relationship between religiosity and mental health (e.g., Bergin, 1983; Bergin, Stinchfield, Gaskin, Masters, & Sullivan, 1988; Bufford, Paloutzian, & Ellison, 1991; DiBlasio & Benda, 1991). Sixth, a small body of literature has developed which examines the use of spiritual interventions in counseling, largely among individuals trained in the context of graduate clinical psychology programs in religious institutions (Moon, Bailey, Kwasny, & Willis, 1991; Jones, Watson, & Wolfram, 1992), and among members of the Christian Association for Psychological Studies, a professional organization of Christian mental health professionals (Adams, 1994; Stratton, 1994). Finally, Malony (1993) advocates the use of religious assessment. He argues that results of this assessment should affect treatment strategies, and concludes “religious diagnosis can play a critical role in decisions made on all five of the axes of DSM-III-R” (p. 115). A number of writers have suggested that spiritual interventions are effective (e.g., Adams, 1970). In the face of claims by those who practice “biblical counseling” that their approaches are more effective (at least with Christian clients), Bufford (1991; 1993) proposed that documentation of these claims is needed. With the dramatic growth in interest in religious issues and interventions, the growth in training in these areas, and the emergence of studies of religious processes in psychotherapy, it seems logical that spiritual outcomes would also become a topic of interest and research. For example, Worthington (1993) states: Spiritual Changes 4 evidence mounts that suggests that religious psychotherapy has no different mental health outcomes with religious clients than does secular psychotherapy. However, religious therapy may have more positive outcomes at strengthening clients’ spiritual resources than does secular therapy. . . . It is incumbent on religious researchers to determine the effects of religious counseling and psychotherapy. (p. 124) A few studies have investigated the effects of spiritual interventions on more traditional outcome measures (Johnson, DeVries, Ridley, Pettorini, & Peterson, 1994; Johnson & Ridley, 1992; Pecheur & Edwards, 1984; Propst, 1980; Propst et al, 1992). However, despite interest in religious issues in psychotherapy and the theoretical arguments for spiritual effects, a recent search was unsuccessful in identifying any published research on religious or spiritual outcomes (for purposes of this article religious and spiritual will be used interchangeably). The entire PsychLit data base was searched (1/74-6/95 for periodicals; 1/1987-6/95 for books and chapters in edited books) for the intersection of the following domains: 1) religious or spiritual; 2) psychotherapy or therapy or counseling; 3) outcome(s) or effect(s) or result(s). A second set of searches looked for: 1) religious or spiritual; 2) outcome(s) or effect(s) or result(s). In all, 48 searches were made in each of the three sections of the data base. Only one study was identified (Groves & Peterson, 1987), but it proved irrelevant to the topic at hand, examining student perceptions of leisure education outcomes. It is possible that this approach to the search is inadequate. Similarly, it seems likely that data exist which bear on the question of religious/spiritual outcomes of psychotherapy which are not indexed under these headings. One such study (Toh , Tan, Osburn, & Faber, 1994) will be discussed later. However, it appears that the question of religious/spiritual outcomes of psychotherapy remains in need of investigation. The Spiritual Well-Being Scale was designed by Ellison and Paloutzian (Ellison, 1983) as an indicator of spiritual health. It has been studied quite extensively, and has been shown the correlate with a wide variety of spiritual measures, including the Religious Orientation Scale-intrinsic religious orientation in particular, the Spiritual Maturity Scale, the Spiritual Leadership Qualities Inventory, self report of importance of religion, frequency of attendance, frequency and duration of personal devotional activity, and profession of Christian faith (Ellison & Smith, 1991). Bufford, Paloutzian, and Ellison (1991) report descriptive data for several groups on the Spiritual Well-Being Scale. They concluded that in addition to being an effective measure of spirituality, the Spiritual Well-Being was also a good measure of general wellbeing, and could be used to identify individuals likely to currently experience emotional or physical problems. In studies of the relationship of spiritual wellbeing and mental health, Sherman (1986) showed that eating disorder inpatients and eating disorder outpatients scored significantly lower on Spiritual Well-Being, Religious Well-Being and Existential Well-Being than a group of medical outpatients. Similarly, Rodriguez (1988) found that a group of sexually abused women currently in outpatient treatment for childhood sexual abuse, or who had been seen for outpatient treatment involving this problem during the past year, scored higher on Religious Well-Being Spiritual Changes 5 than eating disorder inpatients or outpatients, higher on Spiritual Well-Being than eating disorder inpatients, but lower on Spiritual Well-Being, Religious Well-Being and Existential Well-Being than medical outpatients, seminary students, and Youth for Christ staff members. In light of the Sherman and Rodriguez results, it seems likely that the Spiritual Well-Being may be sensitive to mental health treatment effects. Toh, Tan, Osburn, and Faber (1994), in a preliminary investigation of the effectiveness of a lay Christian counseling program conducted through a church in La Canada, CA examined 18 participants at intake and after either 10 or 20 sessions of lay Christian counseling. Since no differences were found between the two groups, all data was reported for the combined groups. They found significant improvement in all self-report measures, including Target Complaints, the Global Severity Index, Positive Symptom Distress Index, Positive Symptom Total on the Brief Symptom Inventory (DeRogatis & Spencer, 1982), and in a counselor rating, the Global Rating Scale. Improvements on measures of psychopathology suggest mental health benefits from this treatment. In addition, and most significant for our purposes, they included the Spiritual Well-Being Scale (Ellison, 1983); scores on the Spiritual Well-Being Scale, and on both the Religious Well-Being and Existential Well-Being subscales, all improved significantly as well. While causal inferences are not warranted from the Toh et al data, they are consistent with the hypothesis that Spiritual Well-Being was enhanced by lay Christian counseling. Insofar as spiritual wellbeing is correlated with mental health, spiritual changes may parallel psychological improvements. Such a finding is significant since there appear to be no existing data documenting spiritual gains as a results of psychotherapy. However, to the extent that the Spiritual Well-Being Scale measures aspects of spiritual functioning which are independent of mental health, gains on this scale suggest that lay Christian counseling may also produce spiritual benefits in addition to, or independent of, mental health gains. Confirmation of such f