Cognitive Behavioral Therapy for Christians with Depression

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Cognitive Behavioral Therapy for Christians with Depression

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

= Michelle Pearce, PhD

TEMPLETON PRESS

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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

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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.

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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

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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

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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

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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

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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

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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.

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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

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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.

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Part One Overview of Christian Cognitive Behavioral Therapy

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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

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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

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