Integration of Religion into

AMBER L. PAUKERT, PhD

LAURA PHILLIPS, PhD
Cognitive-Behavioral Therapy for JEFFREY A. CULLY, PhD
SHEILA M. LOBOPRABHU, MD
Geriatric Anxiety and Depression JAMES W. LOMAX, MD
MELINDA A. STANLEY, PhD

Religion is important to most older adults, and research generally finds a positive relationship between
religion and mental health. Among psychotherapies used in the treatment of anxiety and depression in
older adults, cognitive-behavioral therapy (CBT) has the strongest evidence base. Incorporation of reli-
gion into CBT may increase its acceptability and effectiveness in this population. This article reviews
studies that have examined the effects of integrating religion into CBT for depression and anxiety. These
studies indicate that improvement in depressive and anxiety symptoms occurs earlier in treatment
when CBT incorporates religion, although effects are equivalent at follow-up. The authors present rec-
ommendations for integrating religious beliefs and behaviors into CBT based on empirical literature
concerning which aspects of religion affect mental health. A case example is also included that describes
the integration of religion into CBT for an older man with cognitive impairment experiencing comorbid
generalized anxiety disorder and major depressive disorder. It is recommended that clinicians consider
the integration of religion into psychotherapy for older adults with depression or anxiety and that stud-
ies be conducted to examine the added benefit of incorporating religion into CBT for the treatment of
depression and anxiety in older adults. (Journal of Psychiatric Practice 2009;15:103–112)

KEY WORDS: depression, anxiety, older patients, elderly, religion, spirituality, evidence-based treatment

Depression and anxiety are the most common men- PAUKERT: Veterans Affairs Medical Center, Puget Sound Health
tal health problems reported by elderly individu- Care System, Seattle, WA; PHILLIPS: Michael E. DeBakey
als.1,2 Epidemiologic studies estimate that clinically Veterans Affairs Medical Center and Veterans Affairs South
Central Mental Illness Research, Education and Clinical Center,
significant depressive and anxiety symptoms occur Houston, TX; CULLY, LOBOPRABHU, and STANLEY: Michael
in approximately 10% to 20% of older adults,1,3 and E. DeBakey Veterans Affairs Medical Center, Veterans Affairs
that symptoms of both conditions are often comor- South Central Mental Illness Research, Education and Clinical
bid.4 Depression and anxiety in older adults can have Center, and Menninger Department of Psychiatry and
Behavioral Sciences, Baylor College of Medicine, Houston, TX;
numerous negative consequences, including increas-
LOMAX: Menninger Department of Psychiatry and Behavioral
es in functional impairment, use of medical services, Sciences, Baylor College of Medicine, Houston, TX.
suicide attempts, and nonsuicide mortality.5–7 Copyright ©2009 Lippincott Williams & Wilkins Inc.
Psychotherapy can significantly decrease depressive Please send correspondence and reprint requests to: Amber L.
and anxiety symptoms in older adults (for reviews, Paukert, PhD, Puget Sound Veterans Affairs Medical Center,
see Mackin and Areán8 and Wetherell et al.9). 1660 South Columbian Way, Mail Stop: S-111-HBPC, Seattle, WA
However, drop-out estimates of 20%9,10 and response 98108. Amber.Paukert@va.gov
rates of approximately 50% (e.g., Floyd, et al.,11; This work was supported in part by the Houston VA HSR&D
Stanley et al.,12) suggest that it is important to find Center of Excellence (Houston Center for Quality of Care &
Utilization Studies), HFP90-020, and a pilot grant to the last
ways to improve psychotherapy for depression and author from the South Central Mental Illness Research
anxiety in this population. Integrating religion into Education and Clinical Center (MIRECC).
psychotherapy for older adults with depression and The authors would like to thank Dan Blazer, MD, PhD, of Duke
anxiety may be one way of tailoring treatment to University for his thoughtful comments on an earlier version of
improve its acceptability and effectiveness, as well as the manuscript.
patient adherence. The authors declare no conflicts of interest.

Journal of Psychiatric Practice Vol. 15, No. 2 March 2009 103

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 RELIGION AND COGNITIVE-BEHAVIORAL THERAPY

Scientific interest in the effects of both religion health and broad indicators of quality of life, such as
and spirituality on mental health has increased dra- happiness, satisfaction with life, feelings of well-
matically in recent years.13 Spirituality is defined as being, and self-esteem.20,21 Increased religious
a spiritual relationship with a higher being. Religion involvement also correlates with lower levels of
is defined as beliefs and behaviors shared by a com- depression22,23 and anxiety,21,24 although the evi-
munity.14 Religious beliefs and behaviors are more dence for reduced anxiety is weaker. Religion
clearly defined and quantifiable than spirituality. appears to be particularly important in protecting
They thus have a stronger tradition of scientific against depression in older adults when stressors
exploration and can be more easily and systemati- occur,25 as well as in predicting naturalistic improve-
cally integrated into psychotherapy. Therefore, ment over time in depressive symptoms.26,27 Religion
although spirituality may be a more broadly gener- is also a protective factor against suicide.21
alizable concept, this review will be restricted to the
use of religion in psychotherapy to focus our efforts 3. Religious components can help address com-
on the construct with the most scientific evidence. mon treatment barriers in psychotherapy with
older adults. Treatment resistance and memory
impairment often interfere with psychotherapy
REASONS FOR INCLUDING RELIGION IN
progress in older patients,10,28 and these barriers can
PSYCHOTHERAPY WITH OLDER PATIENTS
be difficult to overcome in the short-term treatments
The idea that religion can be used to bolster the recommended for older adults.10 Strategies that
effects of psychotherapy for older adults with depres- make treatment more meaningful and relevant to
sion and anxiety is based on at least four lines of older adults, such as the integration of religion, may
empirical evidence. increase memory performance,29 acceptability of the
treatment,30 retention in treatment,31 and effective-
1. Religion is important to the majority of older ness,32 even in time-limited courses of therapy.
adults. Most Americans believe in “God or a higher
power” (86%) and over half attend a church or syna- 4. Religious individuals are more likely to enter
gogue (61%), state that religion is “very important” to therapy33,34 and to welcome the inclusion of reli-
them (56%), and believe that religion can answer gion as a component of their psychotherapy.19
almost all of today’s problems (59%).15 These figures Because older adults entering therapy are especially
are even higher among older adults. Three quarters likely to value religion,16 they may welcome its inclu-
of older adults with anxiety or depression participate sion as a potential component of more traditional
in religious activities at least once a month,16 and psychotherapy.
only 9% of older adults state that religion is not
important to them.17 These figures indicate that Thus, there is a strong research basis for consider-
older adults, including those who are experiencing ing the incorporation of religion into psychotherapy
depression or anxiety, are especially likely to consid- for older adults.
er religion as an important part of their lives. Social
disengagement and isolation may cause older adults
GENERAL PRINCIPLES FOR INTEGRATING
to look toward religion for means of coping, social
RELIGION INTO PSYCHOTHERAPY
support, and continued reinforcement.17,18 Older
adults may also be drawn to and benefit from reli- The following broad recommendations for incorpo-
gion because they are coping with end-of-life issues rating religion into psychotherapy are based prima-
and chronic illness. These problems may lead to rily on expert opinion rather than empirical
depression and anxiety without protective factors, evidence.
such as religion.19
1. The decision to incorporate religion into psy-
2. Increased religious involvement is associated chotherapy should be collaborative.35 Therapists
with decreased rates of depression and anxiety. should keep in mind that patients are often uncom-
Religion helps older adults cope with difficult cir- fortable bringing up the topic of religion in therapy.36
cumstances. It is positively associated with mental The therapist can first broach the topic during the

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 RELIGION AND COGNITIVE-BEHAVIORAL THERAPY

intake process, for example, when asking the patient py.39 In addition, discussion of the therapist’s own
to discuss his or her daily activities and life goals. If religion may lead to or be misinterpreted as prosely-
the patient does not mention religion during this dis- tizing, which is likely to harm the therapy relation-
cussion, the clinician should inquire directly whether ship. The potential disruptions in the therapeutic
religion is an important part of the older adult’s life. process caused by revealing a clinician’s religion may
The clinician should raise the topic in a manner that explain why one study found that religious CBT for
allows patients to feel that they may decline the offer depression was most effective when administered by
to discuss their religious beliefs or activities with the nonreligious therapists.40 Although no empirical
clinician. However, if patients indicate that religion data have addressed the effects of matching patients
is important to them and it is a topic they are com- and clinicians with regard to religion,41 clinicians
fortable talking about, the clinician can initiate a may use their knowledge about a patient’s religion to
conversation about how religion affects patients’ life ask questions to elicit further understanding of what
goals and daily thoughts and activities. The clinician the patient’s religion means to him or her and ways
should be alert for any cues that indicate that the to incorporate religion into the healing process.
patient is uncomfortable with the discussion and
explain that integration of religion into psychothera- 4. The clinician should also be aware that cer-
py will remain the prerogative of the patient. For tain types of religious coping are associated
example, some patients may consider religion a part with increased mental health symptomatology.
of their lives that they want to keep separate from Some types of religious feelings, such as complete
psychotherapy. In such a situation, even a slightly deferral to God, a sense of being punished, anger at
coercive integration of religion into psychotherapy and alienation from a religious group, perceptions of
may represent an ethical violation.37 The clinician loss of religion, perceptions of sin, and attributing
and patient together should examine the potential problems to the devil, can actually increase psychi-
benefits and consequences of each religious belief or atric symptoms.42
activity that could be integrated into psychotherapy,
and the final decision to include religion in the ther-
THERAPIES FOR DEPRESSION AND ANXIETY
apy should be collaborative.
IN OLDER ADULTS: EVIDENCE FROM
TREATMENT STUDIES
2. The clinician should not challenge the
patient’s religious beliefs or values. Such chal- Strong empirical evidence supports the use of two
lenges will harm rapport and may decrease the forms of psychotherapy in the treatment of depres-
patient’s motivation for therapy.38 Rather than chal- sion and anxiety in older adults. CBT43 and interper-
lenging a patient’s belief system, the clinician is sonal therapy (IPT)44 for the treatment of depression
encouraged to seek a full understanding of the have the strongest evidence base,45 although few
patient’s religion and how it may inform the treat- studies have examined the efficacy of IPT alone
ment plan. without concurrent medication or pill-placebo in the
treatment of older adults.8 CBT also has the
3. The clinician should carefully weigh the pos- strongest evidence base for the treatment of late-life
sible benefits and consequences of discussing anxiety.9
his or her own religion. This recommendation is Of the different religious-oriented therapies that
based on the potential negative effects of discussion have been proposed, the best empirical evidence
of the clinician’s religion and lack of evidence of ben- exists for CBT that integrates religious components
eficial results from such discussion. Disclosures of (CBT-R).14 CBT-R has been studied in diverse set-
this type may cause the patient to monitor self-dis- tings with individuals from a variety of different
closure, reject a clinician who is not of the same reli- faiths (most commonly, Islam and Christianity) to
gion as the patient, rate clinicians with specific address an array of problems.14 CBT-R for depression
religious orientations as less expert (even if the meets the American Psychological Association’s cri-
patient and clinician have the same religious orien- teria for a well established, empirically validated
tation), apply religious stereotypes to the clinician, treatment,14 since several studies have found that
and/or focus exclusively on religion in psychothera- CBT-R is as effective for depression as CBT40,46 and

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 RELIGION AND COGNITIVE-BEHAVIORAL THERAPY

more effective than placebo (e.g., supportive therapy) frequency of religious behaviors may increase the
for depression.47,48 Although CBT-R for anxiety does effectiveness of CBT for religious older adults. In the
not meet these same criteria, controlled trials have following sections, we first discuss integration of reli-
shown it to be more effective than supportive psy- gious beliefs and then consider integration of reli-
chotherapy for middle-aged49 and young patients.50 gious behaviors.
Although several studies found that CBT-R leads to
more rapid decreases in symptomatology than sup- Integrating Religious Beliefs into CBT
portive psychotherapy, both CBT-R and supportive
psychotherapy produced similar results after a fol- Religious beliefs and scriptures can be helpful in
low-up period.47–50 A more complete discussion can modifying maladaptive thoughts and behaviors that
be found in reviews of studies that integrate religion are associated with negative moods. Religious think-
into psychotherapy (e.g., Paukert et al., Systematic ing can be implemented as a strategic response to
review of the effects of religion-accommodative psy- stressful situations to encourage more adaptive
chotherapy for depression and anxiety, unpublished thought patterns (rational responses). Self-state-
manuscript).14,22,51 ments with religious connotations (e.g., “God will
Although the evidence for CBT-R is encouraging, give me the strength to get through this,”53) or scrip-
more research is necessary. Most studies in this tural quotations (e.g., “Commit to the Lord whatever
domain have involved small samples of patients, did you do, and your plans will succeed,” Proverbs
not adequately explain how religion was integrated 16:354,55) can be positive cognitive coping responses
into treatment, and did not describe important when stressful stimuli occur. The integration of reli-
methodological information, such as whether and gious beliefs and scripture into the formulation of
how randomization was performed. Few manuals for rational responses may enhance their acceptability
integrating religion into psychotherapy are refer- and the chances that they will be remembered, thus
enced in studies examining the efficacy of CBT-R, making them more likely to be beneficial for at least
and manuals that have been identified (e.g., the some subgroups of older adults than rational
manual by Propst et al.40 used in their randomized responses without religious content.
controlled trial of CBT-R52) do not give clear instruc- Evidence indicates that religious beliefs can pro-
tions for integrating religion into psychotherapy. In vide relief from stress. Religion may enhance percep-
addition, no studies to date have examined the tions of control by a beneficent God, which is
effects of integrating religion into the treatment of especially important when one experiences a reduc-
depression or anxiety among older adults, a popula- tion of one’s own personal control, such as when older
tion in which this approach may have the most adults suffer from chronic health conditions.39,56
potential benefit. Religion may also decrease stress by reducing the
perceived harm associated with stressful situations
and promoting the thought that one will be able to
INTEGRATING RELIGION INTO CBT
cope effectively. Beliefs such as, “God is a just and
In the following sections, we present recommenda- benevolent God,” “God is one’s partner through suf-
tions for integrating religion into CBT treatment for fering,” “Religious rituals provide a sense of security,”
anxiety and depression in older adults based on stud- and “Religion provides support,” can help people cope
ies that have demonstrated benefits of certain in difficult circumstances57 by encouraging a sense of
aspects of religion for mental health. CBT in general meaning, purpose,39 and self-esteem.25 Without such
is based on the assumption that symptoms of anxiety coping responses, significant life stressors may cause
and depression are mediated by maladaptive the person to feel that all hope is lost.
thoughts and behaviors, which can be modified to Religious beliefs may also help older adults look at
reduce anxiety and depression. In CBT, clinicians and situations from a different perspective, and clini-
patients collaborate to challenge irrational thoughts; cians can then show patients how to use this new
clinicians also encourage patients to engage in activ- perspective to improve their coping responses and
ities that provide opportunities for positive reinforce- mood. For example, clinicians can encourage older
ment. Integrating religious beliefs into the process of adults to consider what role the higher being plays in
challenging irrational thoughts and increasing the their daily life according to their faith. If an individ-

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 RELIGION AND COGNITIVE-BEHAVIORAL THERAPY

ual believes that a higher being is always with him In integrating religious beliefs into psychotherapy,
or her, guided imagery can be used to help the clinicians use the same process involved in incorpo-
patient sense the presence of a higher being while in rating other belief systems in cognitive restructuring.
distress. Some older adults may find that thinking First, the clinician inquires about the patient’s reli-
about their religion results in a feeling that they are gious background and beliefs. Second, the patient is
never alone, leading to improved mood. Clinicians assigned the task of self-monitoring his or her
can also encourage individuals to think about how thoughts, feelings, and behaviors in specific situa-
life problems are conceptualized in their religion and tions and recording any thoughts that occur. Third,
this conceptualization may help change the way they the patient is encouraged to consider religious beliefs
perceive stressors. For example, stressors may be as evidence in restructuring negative maladaptive
conceptualized as tests of faith, acts of a higher being thoughts. For example, clinicians can encourage
the reasons for which cannot be known by the patients to identify religiously oriented evidence or
patient, or pathways to a better life. Religion has the adaptive responses by inquiring about ways that reli-
potential to increase hope, optimism,39 and feelings gion has helped them cope in the past, religious
of self-worth, even in the face of life-threatening ill- teachings or beliefs that might be relevant to the sit-
ness.58 The relationship between religion and uation, what they might say to someone from their
improved mental health21 may be mediated by reli- religious community who is having similar thoughts,
gion’s ability to foster a sense of hope, provide com- or what their religion or religious leaders teach on
fort and a feeling of being cared for, and give a sense the topic. A religious-oriented coping statement can
of not being alone.59 then be developed as an adaptive thought to be used
Conversely, if individuals do not appear capable of in stressful situations. As discussed above, the
revising their maladaptive beliefs and behavior pat- patient may draw on a number of different sources,
terns with their religious knowledge and beliefs, or if including beliefs such as “God will help me through
their religious beliefs seem to be leading to increased this situation,” quotations from religious texts, and/or
anxiety or depression, the clinician’s role may be to religious teachings, in creating this coping response.
encourage the individual to seek spiritual guidance The potential of religious beliefs to have a positive
from sacred texts or a trusted source of religious effect on mental health has been recognized by the
knowledge.51 The clinician can then help the individ- scientific community. For example, the cognitive
ual interpret information obtained from such a reli- model of stress and coping presented by Lazarus
gious professional in an adaptive way. Developing such and Folkman61 has been modified to include reli-
an adaptive interpretation involves using the same gious beliefs.57 Patterns of religious belief influence
cognitive-restructuring techniques that are used to the ways in which individuals perceive the world
counteract nonreligious negative automatic thoughts. and result in a form of natural cognitive restructur-
Because the process of cognitive restructuring is ing.62 Integrating religious beliefs into CBT capital-
complicated, new adaptive thoughts can be difficult izes on the potential of religious beliefs to have a
to remember, especially for older adults as working positive effect on mental health in the context of
memory declines with age.60 However, religious psychotherapy.
beliefs may represent a form of “crystallized” intelli-
gence; and such well established knowledge systems Integrating Religious Behaviors into CBT
may not decline as much with age as “fluid” intelli-
gence, which involves the ability to perform new CBT clinicians also encourage behavioral activation,
tasks, learn new information, and solve new prob- or planned increases in achievement-oriented and
lems.29 Thus, well established religious beliefs and pleasurable activities, because such activities
activities may be able to function as a bridge increase the likelihood that the person will receive
between younger and older adult memory perform- positive reinforcement and improve his or her mood.
ance to help older patients acquire new skills. Anxiety and depression are often associated with
Consequently, integrating religion into cognitive avoidance of activities in many areas of life that can
restructuring may improve the ability of older adults lead to a lack of positive reinforcement. When indi-
to benefit from more cognitively demanding thera- viduals are depressed, they frequently neglect effort-
peutic techniques. ful, nonessential activities of daily life, such as

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 RELIGION AND COGNITIVE-BEHAVIORAL THERAPY

socializing and travel. Anxiety leads individuals to the underlying motivation for religious activities par-
avoid anxiety-producing activities, which results in tially determines the effect of these activities on men-
limited opportunities for reinforcement. Involvement tal health. Assessment of the importance of religious
in organized religious activities may increase oppor- activities in meeting patients’ life goals may help
tunities for positive reinforcement, which in turn determine whether religious activities would be
may further protect against and alleviate the effects intrinsically or extrinsically rewarding. Activities
of stressors.63 Thus, clinicians can encourage atten- that are concordant with a patient’s life goals would
dance at religious functions as a form of behavioral be intrinsically rewarding and appropriate targets
activation. for behavioral activation.70 It would thus be thera-
Empirical evidence indicates that religious activi- peutically indicated to encourage older adults to
ties, such as attending services and volunteering, are engage in religious activities if they provide fulfill-
forms of behavioral activation that are effective in ment and increase the likelihood of internal rein-
reducing and protecting against depression in older forcement.71 Religious activities such as participating
adults.64,65 Attendance at worship reduces the risks in organized activities, reading sacred texts, or volun-
of developing depressive and anxiety disorders,64 and teering may help a religious older adult feel pleasure
it may provide protection against the negative effects or accomplishment and lead to reductions in depres-
of stress.66 Religious activity is associated with fewer sive symptoms if the motivation for these behaviors is
depressive symptoms20 and remission of depression intrinsic .
in several populations,65 including medically ill older In CBT for anxiety, an important component is
adults.67 In a large study of 1,610 older adults par- exposure to feared situations. Religious activities
ticipating in a treatment study for depression, more may also serve as a form of exposure therapy. Church
frequent attendance at religious services was associ- attendance may be an effective exposure exercise for
ated with less emotional distress, suicidal ideation, a patient with social anxiety and agoraphobia.9
and diagnoses of depression or anxiety disorders.16 Going on religious group outings or participating in
In addition, individuals who participated in religious religiously oriented work groups may serve a similar
activities showed more improvement when they function. Encouraging religious activities as expo-
received mental health services.16 McCullough and sure exercises may be an effective strategy because
Larson22 reviewed over 80 studies examining the older adults with strong religious beliefs may be par-
relationship between religious involvement and ticularly motivated to participate in religious activi-
depression. They found several particularly interest- ties even if they provoke anxiety.
ing trends relevant to the potential value of religious Prayer can be another important coping mecha-
behavioral activation. First, organized religious nism for older adults with depression and anxiety.
activities decreased the risk of major depression For patients who value religious activity, prayer can
(risk was reduced by 20% to 60% for individuals be incorporated into CBT as a positive behavior and
involved in organized religious activities).22 Addi- coping mechanism. Older adults often cope by pray-
tionally, organized religious participation was more ing. For example, praying is the coping strategy that
strongly associated with reduced depressive symp- elderly women with medical problems are most like-
toms than private religious activities or beliefs.22,68 ly (91%) to employ, with seeing a physician, resting,
However, the psychological benefits of participating using medications, or seeking information about
in religious activities may occur only if the patient’s their illness secondary strategies.72 In addition,
reasons for participation are intrinsic and not prayer predicted positive adjustment to disability in
extrinsic. a longitudinal study of 394 older adults with knee
Intrinsic religiosity, defined as religion that is rein- pain.73 However, when other religious variables (e.g.,
forcing because of the fulfillment one feels as a result worship attendance, intrinsic religiousness, and reli-
of its beliefs and practice,69 is correlated with lower gious coping) were controlled, no added effect of
depression scores20 and naturalistic remission from prayer was noted among 88 depressed men admitted
depression.67 However, extrinsic religiosity, in which to an inpatient psychiatric unit.20
religious activities are performed to receive external Despite some encouraging evidence, the effects of
reinforcements (e.g., praise, higher social status), is prayer on mental health are not uniformly positive
correlated with higher rates of depression.20 Thus, or even neutral. A survey of 560 randomly selected

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 RELIGION AND COGNITIVE-BEHAVIORAL THERAPY

households revealed that different types of prayers related to physical health problems.76 Elderly indi-
were associated in different ways with well being viduals who are experiencing life-threatening ill-
and life satisfaction.74 Non-ritualistic prayers, in nesses may perceive religious social support as even
which one engages in discourse with a higher being, stronger than support from family or friends.78
may be adaptive, as they are associated with higher The determination of whether and how to inte-
levels of well being and life satisfaction; whereas rit- grate religious activities into psychotherapy should
ualistic (pre-determined) prayers may be maladap- occur after an assessment of the role religion plays in
tive, as they have negative associations with well the patient’s life and collaboration with the patient.
being.74 However, as with other religious activities, The clinician should first assess what role religion
the purpose of prayer rather than the type of prayer plays in the patient’s life values; what activities are
may determine its impact on mental health. Prayer available within the religious group with which the
used as a passive coping style (avoidance) in which person identifies; and what activities the patient has
the individual completely relinquishes control over a previously been involved with. Next, the clinician
stressor may not be an effective coping mechanism can work with the patient to identify activities the
and may even increase negative thoughts. patient would like to be involved in based on his or
Supporting this hypothesis is a study of 105 chronic her goals and interests. Older adults are often no
pain patients in which prayer was associated with longer capable of continuing past activities because
avoidance and increased disability.75 Thus, if prayer of deficits in different areas of functioning, including
is to be used as a coping tool in psychotherapy, clini- cognition, eyesight, hearing, or physical mobility.
cians should carefully explore how patients are using Using a collaborative process, the clinician can help
prayer. Prayer can be de-emphasized in therapy if it the patient adapt past or new desired activities to be
is being used as an avoidance strategy but encour- feasible for the person to undertake given his or her
aged if it is being used for self-reflection and collabo- current capabilities. For example, a patient may be
ration with a higher being, as the latter has positive unable to drive to church because of failing eyesight.
effects on mental health.74 The clinician can help the patient identify alterna-
In addition to increasing positive reinforcement, tive forms of transportation that might help him or
behavioral activation, exposure, and prayer may help her get to church or may suggest other options.
patients restructure maladaptive thoughts. For Several options can be identified, with the patient
example, the adaptive forms of prayer that involve choosing the best one.
talking with a higher being as a form of collaboration
and reflection may change negative thoughts into Case Example: Integrating Religion into CBT
more adaptive thoughts. In addition, if a patient
believes he or she will not enjoy interacting with oth- Mr. P was a married 83-year-old Hispanic man with
ers or is fearful of such interactions, attending a reli- vascular dementia. Prior to beginning treatment, he
gious meeting may provide evidence against these was diagnosed with generalized anxiety disorder and
beliefs. major depressive disorder. His stressors included
Increased religious activities may also improve health problems, falling about once a week, financial
both actual and perceived levels of social support, problems, death of family members, and worry about
which in turn can decrease depression and anxiety.76 the future. Because of his memory problems, his wife
Social support received from religious communities was asked to act as a coach to help him learn the
can be important in preventing and helping older tools he was being taught in CBT to try to reduce his
adults recover from anxiety and depression. Social sadness and worries. Religion was not directly pre-
support, in general, is a protective factor for older sented as a possible avenue to focus CBT techniques
adults’ mental health;2 and older adults frequently but naturally arose as part of the therapeutic
use their local faith communities as a means of social process, as it was important to the couple.
and instrumental support.77 Social support from a Mr. P’s religious beliefs were integrated into his
religious community may reduce stress, even when treatment to help him cope with worries about
religious beliefs do not.66 Thus, social support may finances and his wife’s health. He reported that he
mediate the relationship between religion and men- believed God would take care of him. Religious cop-
tal health, especially in the presence of stressors ing statements that were familiar helped Mr. P

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 RELIGION AND COGNITIVE-BEHAVIORAL THERAPY

remember his rational responses. Given his memory CBT for older adults with depression or anxiety. It is
impairment, this was especially important for Mr. P. hoped that further research will be spurred by the
Before beginning therapy, Mr. P rarely left his house. recommendations presented here and that such
His wife went to church weekly, but he reported that research will provide a guide for clinicians in inte-
he did not go because he was afraid of falling. His grating religion into CBT. Researchers and clinicians
wife reported that there was a special pew for hand- integrating religion into empirically validated treat-
icapped individuals that reduced chances of falling, ments, such as CBT for late-life anxiety and depres-
but Mr. P did not want to sit there with “all those old sion, may be well-rewarded with increased
handicapped people.” He said he was afraid of what acceptance and engagement in treatment.80
other people would think about him. However, after
discussing his thoughts about the people who sit in
the “handicapped” row, Mr. P realized that he did not References
think negatively of those individuals, so other people 1. Baker FM. An overview of depression in the elderly: A US
should not think negatively of him for sitting there. perspective. J Natl Med Assoc 1996;88:178–84.
Mr. P was also asked what God thought about his 2. Beekman ATF, Bremmer MA, Deeg DJH, et al. Anxiety
going to church and he reported that God wanted disorders in later life: A report from the Longitudinal
him to go. Because this was something he was doing Aging Study Amsterdam. Int J Geriatr Psychiatry 1998;
13:717–26.
for God, the embarrassment he might feel about sit- 3. Sable JA, Jeste DV. Anxiety disorders in older adults. Curr
ting in the handicapped pew was reframed as a sac- Psychiatry Rep 2001;3:302–7.
rifice for God. Mr. P was encouraged to go with his 4. Hocking LB, Koenig HG. Anxiety in medically ill older
wife the next time she went to church, by telling him- patients: A review and update. Int J Psychiatry Med 1995;
self, “I am doing this for God.” Religion was chosen as 25:221–38.
5. Blazer DG. Depression in late life: Review and commen-
the first behavioral-activation technique in this case tary. J Gerontol A Biol Sci Med Sci 2003;58A:249–65.
for several reasons: it provided internal reinforce- 6. Cassidy EL, Lauderdale S, Sheikh JI. Mixed anxiety and
ment, Mr. P was highly motivated to do the activity, depression in older adults: Clinical characteristics and
and it was an activity that would allow increased management. J Geriatr Psychiatry Neurol 2005;18:83–8.
socialization with his wife and others. 7. Lauderdale SA, Sheikh JI. Anxiety disorders in older
adults. Clin Geriatr Med 2003;19:721–41.
Mr. P went to church the week after he discussed 8. Mackin RS, Areán PA. Evidence-based psychotherapeutic
the issue with the clinician and reported that he was interventions for geriatric depression. Psychiatr Clin
surprised to discover that people said they had North Am 2005;28:805–20.
missed him. He did not feel embarrassed, and he did 9. Wetherell JL, Lenze EJ, Stanley MA. Evidence-based
not fall. After this, he began walking regularly and treatment of geriatric anxiety disorders. Psychiatr Clin
North Am 2005;28:871–96.
renewing social ties. Attending church seemed to sig- 10. Pinquart M, Duberstein PR, Lyness JM. Effects of psy-
nificantly benefit Mr. P, as it behaviorally activated chotherapy and other behavioral interventions on clinical-
him, increased his social support, and challenged his ly depressed older adults: A meta-analysis. Aging Ment
negative automatic thoughts. If he had not been so Health 2007;11:645–57.
motivated by his faith to complete this first behav- 11. Floyd M, Scogin F, McKendree-Smith NL, et al. Cognitive
therapy for depression: A comparison of individual psy-
ioral-activation exercise, his improvement might chotherapy and bibliotherapy for depressed older adults.
have been slower or might not have occurred at all. Behav Modif 2004;28:297–318.
12. Stanley MA, Beck JG, Novy DM, et al. Cognitive-behav-
ioral treatment of late-life generalized anxiety disorder. J
CONCLUSION Consult Clin Psychol 2003;71:309–19.
13. Koenig HR. Religion and medicine II: Religion, mental
Religion is important to many older adults,17 and health, and related behaviors. Int J Psychiatry Med 2001;
they often want it to be considered in treatment.19 31:97–109.
Religion has been reported to speed up the effects of 14. Hodge DR. Spiritually modified cognitive therapy: A
CBT in younger depressed or anxious populations49 review of the literature. Soc Work 2006;51:157–66.
15. Gallup Poll 2007. Religion (available at www.gal-
and both epidemiological and experimental litera-
lup.com/poll/1690/Religion.aspx, accessed January 10,
ture indicate it is important in helping older adults 2009).
cope with stress.51,79 Treatment studies are needed to 16. Chen H, Cheal K, Herr ECM, et al. Religious participation
explore the benefits of incorporating religion into as a predictor of mental health status and treatment out-

110 March 2009 Journal of Psychiatric Practice Vol. 15, No. 2

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 RELIGION AND COGNITIVE-BEHAVIORAL THERAPY

comes in older persons. Int J Geriatr Psychiatry 2007;22: Ethical issues and principles to consider. J Clin Psychol
144–53. 2007;63:891–902.
17. Newport F. Religion most important to blacks, women, and 36. Meador KG, Koenig HG. Spirituality and religion in psy-
older Americans, 2006 (available at www.gallup.com chiatric practice: Parameters and implications. Psychiatr
/poll/25585/Religion-Most-Important-Blacks-Women- Ann 2000;30:549–55.
Older-Americans.aspx, accessed January 13, 2009). 37. Lomax JW, Karff RS, McKenny GP. Ethical considerations
18. Wink P, Dillon M. Spiritual development across the adult in the integration of religion and psychotherapy: Three
life course: Findings from a longitudinal study. J Adult perspectives. Psychiatr Clin North Am 2002;25:547–59.
Dev 2002;9:79–94. 38. Morrow D, Worthington EL, McCullough ME. Observers’
19. Lee BY, Newberg AB. Religion and health: A review and perceptions of a counselor’s treatment of a religious issue.
critical analysis. Zygon 2005;40:443–68. J Couns Dev 1993;71:452–56.
20. Baetz M, Larson DB, Marcoux G, et al. Canadian psychi- 39. Worthington EL Jr, Kurusu TA, McCollough ME, et al.
atric inpatient religious commitment: An association with Empirical research on religion and psychotherapeutic
mental health. Can J Psychiatry 2002;4:159–66. processes and outcomes: A 10-year review and research
21. Van Ness PH, Larson DB. Religion, senescence, and men- prospectus. Psychol Bull 1996;119:448–87.
tal health: The end of life is not the end of hope. Am J 40. Propst LR, Ostrom R, Watkins P, et al. Comparative effi-
Geriatr Psychiatry 2002;10:386–97. cacy of religious and nonreligious cognitive-behavioral
22. McCullough ME, Larson DB. Religion and depression: A therapy for the treatment of clinical depression in reli-
review of the literature. Twin Res 1999;2:126–36. gious individuals. J Consult Clin Psychol 1992;60:94–103.
23. Wink P, Scott J. Does religiousness buffer against the fear 41. Mayers C, Leavey G, Vallianatour C, et al. How clients
of death and dying in late adulthood? Findings from a lon- with religious or spiritual beliefs experience psychological
gitudinal study. J Gerontol B Psychol Sci Soc Sci. 2005; help-seeking and therapy: A qualitative study. Clin
60:P207–14. Psychol Psychother 2007;14:317–27.
24. Tapanya S, Nicki R, Jarusawad O. Worry and intrinsic/ 42. Pargament KI, Murray-Swank NA, Tarakeshwar N.
extrinsic religious orientation among Buddhist (Thai) and Editorial: An empirically-based rationale for a spiritually-
Christian (Canadian) elderly persons. Int J Aging Hum integrated psychotherapy. Ment Health Relig Cult 2005;8:
Dev 1997; 44:73–83. 155–65.
25. Musick MA, Koenig HG, Hays JC, et al. Religious activity 43. Beck AT, Rush J, Shaw BF, et al. Cognitive therapy of
and depression among community-dwelling elderly per- depression. New York: Guilford Press; 1979.
sons with cancer: The moderating effect of race. J Gerontol 44. Klerman GL, Weissman MM, Rounsaville BJ, et al. Inter-
B Psychol Sci Soc Sci 1998;53B:S218–27. personal psychotherapy of depression. New York:
26. Koenig HG, Cohen HJ, Blazer DG, et al. Religious coping Academic Press, Basic Books; 1984.
and depression among elderly, hospitalized medically ill 45. American Psychiatric Association. Practice guidelines for
men. Am J Psychiatry 1992;149:1693–700. the treatment of patients with major depressive disorder
27. Pressman P, Lyons JS, Larson DB, et al. Religious belief, (revision). Am J Psychiatry 2000;157:1–49.
depression, and ambulation status in elderly women with 46. Peucher DR, Edwards KJ. A comparison of secular and
broken hips. Am J Psychiatry 1990;147:758–60 religious versions of cognitive therapy with depressed
28. Lundervold DA, Young LG. Older adults’ attitudes and Christian college students. Journal of Psychology &
knowledge regarding the use of mental health services. J Theology 1984;12:45–54.
Clin Exp Gerontol 1992;14:45–55. 47. Razali SM, Hasanah CI, Aminah K, et al. Religious-socio-
29. Satre DD, Knight BG, David S. Cognitive-behavioral inter- cultural psychotherapy in patients with anxiety and
ventions with older adults: Integrating clinical and geron- depression. Aust NZ J Psychiatry 1998;32:867–72.
tological research. Prof Psychol Res Pr 2006;37:489–98. 48. Azhar MZ, Varma SL. Religious psychotherapy in depres-
30. Alvidrez J, Areán PA, Stewart AL. Psychoeducation to sive patients. Psychother Psychosom 1995;63:165–73.
increase psychotherapy entry for older African Americans. 49. Azhar MZ, Varma SL, Dharap AS. Religious psychothera-
Am J Geriatr Psychiatry 2005;13:554–61. py in anxiety disorder patients. Acta Psychiatr Scand
31. Hopwood C, Ambwani S, Morey L. Predicting nonmutual 1994;90:1–3.
therapy termination with the Personality Assessment 50. Razali SM, Aminah K, Khan UA. Religious-cultural psy-
Inventory. Psychother Res 2007;17:706–12. chotherapy in the management of anxiety patients.
32. Sotsky SM, Glass DR, Shea MT, et al. Patient predictors of Transcult Psychiatry 2002;39:130–6.
response to psychotherapy and pharmacotherapy: Find- 51. Smith TB, Bartz J, Richards PS. Outcomes of religious and
ings in the NIMH Treatment of Depression Collaborative spiritual adaptations to psychotherapy: A meta-analytic
Research Program. Am J Psychiatry 1991;148: 997–1008. review. Psychother Res 2007;17:643–55.
33. Godwin TC, Crouch JG. Subjects’ religious orientation, 52. Propst LR. Psychotherapy in a religious framework:
counselor’s orientation and skill, and expectations for Spirituality in the emotional healing process. New York:
counseling. J Psychol Theol 1989;17:284–92. Human Sciences Press; 1988.
34. Pecnik JA, Epperson DL. Analogue study of expectations 53. Nielsen SL, Ridley CR, Johnson WB. Religiously sensitive
for Christian and traditional counseling. J Couns Psychol rational emotive behavior therapy: Theory, techniques,
1985;32:127–30. and brief excerpts from a case. Prof Psychol Res Pract
35. Plante TG. Integrating spirituality and psychotherapy: 2000;31:21–8.

Journal of Psychiatric Practice Vol. 15, No. 2 March 2009 111

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 RELIGION AND COGNITIVE-BEHAVIORAL THERAPY

54. Holy Bible, New International Version. Colorado Springs: J Psychiatry 1998;155:536–42.
International Bible Society; 1984. 68. Kendler KS, Gardner CO, Prescott CA. Religion, psy-
55. Ball RA, Goodyear RK. Self-reported professional practices chopathology, and substance use and abuse: A multimea-
of Christian psychotherapists. Journal of Psychology and sure, genetic-epidemiologic study. Am J Psychiatry 1997;
Christianity 1991;10:144–53. 154:322–9.
56. Cole B, Pargament, K. Re-creating your life: A spiritual/ 69. Bergin AE. Religiosity and mental health: A critical reeval-
psychotherapeutic intervention for people diagnosed with uation and meta-analysis. Prof Psychol Res Pract
cancer. Psychooncology 1999;8:395–407. 1983;14:170–84.
57. Pargament KI, Ensing DS, Falgout K, et al. God help me: I. 70. Hopko DR, Lejuez CW, Ruggiero KJ, et al. Contemporary
Religious coping efforts as predictors of the outcomes to behavioral activation treatments for depression:
significant negative life events. Am J Community Psychol Procedures, principles, and progress. Clin Psychol Rev
1990;18:793–824. 2003;23:699–717.
58. Roberts JA, Brown D, Elkins T, et al. Factors influencing 71. Lomax JW. Religious participation and caregiving: A psy-
views of patients with gynecologic cancer about end-of-life chodynamic perspective. In: Loboprabhu SM, Molinari V,
decisions. Am J Obstet Gynecol 1997;176:166–72. Lomax JW, eds. Supporting the caregiver in dementia: A
59. Lindgren KN, Coursey RD. Spirituality and serious mental guide for health care professionals. Baltimore: John
illness: A two-part study. Psychosoc Rehabil J 1995;18: Hopkins University Press; 2006:104–16.
93–111. 72. Conway K. Coping with the stress of medical problems
60. Light LL. Memory changes in adulthood. In: Qualls SH, among black and white elderly. Int J Aging Hum Dev 1985-
Abeles N, eds. Psychology and the aging revolution: How 86:21:39–48.
we adapt to longer life. Washington, DC: American Psycho- 73. Rapp SR, Rejeski WJ, Miller ME. Physical function among
logical Association; 2000:73–97. older adults with knee pain: The role of pain coping skills.
61. Lazarus RS, Folkman S. Stress, appraisal, and coping. New Arthritis Care Res 2000;13:270–9.
York: Springer; 1984. 74. Poloma MM, Pendleton BF. The effects of prayer and
62. Lupfer MB, Brock KF, DePaola SJ. The use of secular and prayer experiences on measures of general well-being. J
religious attributions to explain everyday behavior. J Sci Psychol Theol 1991;19:71–83.
Study Relig 1992;31:486–503. 75. Ashby JS, Lenhart RS. Prayer as a coping strategy for
63. Lewinsohn PM, Hoberman H, Teri L, et al. An integrative chronic pain patients. Rehabil Psychol 1994;39:205–9.
theory of depression. In: Reiss S, Bootzin, RR, eds. 76. Hughes JW, Tomlinson A, Blumenthal JA, et al. Social sup-
Theoretical issues in behavior therapy. San Diego: port and religiosity as coping strategies for anxiety in hos-
Academic Press; 1985:331–59. pitalized cardiac patients. Ann Behav Med 2004;28:
64. Baetz M, Bowen R, Jones G, et al. How spiritual values and 179–85.
worship attendance relate to psychiatric disorders in the 77. Bohannon JR. Religiosity related to grief levels of bereaved
Canadian population. Can J Psychiatry 2006;51: 654–61. mothers and fathers. Omega 1991;23:153–9.
65. Braam AW, Beekman ATF, van Tilburg TG. Religious 78. Ingram SS, Seo PH, Martell RE, et al. Comprehensive
involvement and depression in older Dutch citizens. Soc assessment of the elderly cancer patient: The feasibility of
Psychiatry Psychiatr Epidemiol 1997;32:284–91. self-report methodology. J Clin Oncol 2002;20:770–5.
66. Williams DR, Larson DB, Buckler RE, et al. Religion and 79. Tepper M, Whitehead J. Cognitive therapy and preventing
psychological distress in a community sample. Soc Sci Med suicide attempts. JAMA 2005;294:2847.
1991;32:1257–62. 80. Pargament KI, Saunders SM. Introduction to the special
67. Koenig HG, George LK, Peterson BL. Religiosity and issue on spirituality and psychotherapy. J Clin Psychol
remission of depression in medically ill older patients. Am 2007;63:903–7.

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