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Using religious texts to bolster an already-effective form of psychotherapy.

Cognitive behavioral therapy (CBT) is one of the most effective forms of psychological intervention for depression and other disorders. Therapists guide patients through specific exercises to identify and change unhelpful thought processes and their resulting behaviors. In part because of its limited duration and specific format, CBT is also one of the forms of therapy with the most experimental backing — it works, which we know from several studies that have shown it works.

At first glance, religious belief seems ill-suited to the kind of controlled randomized testing that has given CBT its revered place in modern psychiatry — a researcher can’t randomly assign someone a religion for 12 weeks and expect meaningful results. But the team led by Dr. Harold Koenig at Duke University’s Center for Spirituality, Theology and Health has found a way to integrate religion into CBT — and found evidence that religious faith can help extend the success of a CBT regimen.

A FIVEFOLD PATH

As the basis for their study, Koenig and his team developed a basic non-religious CBT curriculum and then adapted it into versions for adherents of five major religious traditions — Christianity, Judaism, Islam, Buddhism, and Hinduism. The curricula all retained elements common to CBT like identifying negative thoughts, setting goals, and undertaking homework between sessions, but each took on its own flavor with quotations from key texts and thinkers from each religious tradition. For instance, in a section on how to challenge unhelpful thoughts, the curricula direct patients to memorize a relevant excerpt from the Old and New Testaments, the Koran, the Bhagavad Gita, or the Dhammapada (sayings of the Buddha).

For Koenig’s study, 132 subjects who suffered from depression related to chronic illness were recruited and randomly assigned the secular or religious versions of the therapy. In a series of publications following the study’s completion in 2014, Koenig and his colleagues attempted to tease apart the results. Religious CBT was at least as effective as the secular version, but the most notable difference was that patients who received the religious curricula were more likely to complete the full curriculum, ensuring that more of them could receive the full benefit of the therapy.

WAYS FORWARD

Koenig’s results indicate at least two paths for further research. One path concerns the feasibility of implementing religious components of CBT in a clinical setting. In the first study, the addition of religious portions to the curriculum often left therapists pressed for time compared to those who only had to cover the standard CBT content with their patients. Encouragingly, however, the religious CBT therapies were just as effective whether or not the therapist had the same religious background as the patient — making it a potentially useful tool even for therapists who treat a wide range of patients.

A second branch of inquiry has Koenig’s team adapting the curricula as an intervention for treating soldiers with post-traumatic stress disorder. Rather than general depression, this approach focuses on “moral injury” — the recently recognized complex of guilt, shame, religious struggles, and loss of faith that result from witnessing and participating in warfare.

BUILDING ON A LEGACY

Koenig says that his interest in the possibilities of religious CBT was a progression from his decades of work on the intersection of religious belief and medical practice. “All of this is really a natural evolution of research and interests over a 35 year period,” he says. And although his efforts to help medicine and psychiatry learn and benefit from patients’ and practitioners’ religious backgrounds might seem groundbreaking, he sees it as part of a far larger continuum. “Psychology has only been around about 100 years,” he notes. “What about the prior four thousand years? Religious beliefs and practices have been how people coped with trauma and stress.”