Constructing a trail up the mountain of intradisciplinary integration.

Worthington, Everett L., Jr.

Twenty years have passed since Worthington (1994) wrote an article on intradisciplinary integration. He contrasted intradisciplinary integration--creating a theory of psychotherapy--with interdisciplinary integration in which one attempted to synthesize a combination of the disciplines of psychology and theology, which had dominated the integration conversation to that time. He based the approach on clinical experience and reflections of integrationists, but not on much empirical research. The failure to recommend collecting empirical evidence of a treatment's efficacy in Worthington's "blueprint" article reflected the world of the early 1990s.

In 1994, though, managed care was in its infancy. Evidence supporting religiously accommodated psychotherapy was just beginning to accumulate. It was not until 1996 (Worthington, Kurusu, McCullough, & Sandage, 1996) when a major review considered bringing evidence together on religiously accommodated treatments. A few years later, McCullough (1999), found only five randomized clinical trials of Christian accommodative psychotherapy--all of which studied Christian cognitive-behavior therapy (CBT).

Suddenly, though, things accelerated. At first, the public pressure mounted to develop research support for the use of "empirically validated treatments" (Chambless, Sanderson, Shoham, Bennett-Johnson, Pope, Crits-Christoph,s et al., 1996), which gave way to the term "empirically supported treatments" (ESTs; Chambless & Hollon, 1998; Chambless & Ollendick, 2001), which was considered a more definitionally hygienic term. ESTs were defined as being at least two manual-driven randomized clinical trials (RCTs) of an approach that come from at least two independent labs and both show the treatment to be superior to controls or equal to an established different EST.

But that restrictive criterion, though still a gold standard, has yielded to "evidence-based treatments" (EBTs; American Psychological Association, 2005; Kazdin, 2008). EBTs permit the researcher to consider not only RCTs but many other forms of evidence supporting the treatment, thus providing a stronger and more well-rounded case for a treatment's use. However, the label tells the reader less about the quality of support than did designation as an EST. For example, a single case study could be considered "evidence" supporting a treatment. That imprecision of definition should send the reader scurrying to the research literature to evaluate the quality of evidence, but it rarely does. Instead, to make credible claims that a treatment is indeed a respectable EBT, the one making the claim must self-police to include a variety of types of evidence, including (in the best cases) meeting the criteria for empirically supported treatments and adducing much more evidence besides. For example, an excellent EBT would have efficacy evidence including case studies, A = 1 studies using multiple-baselines and A-B-designs, and RCTs from multiple independent labs. It would also have evidence of effectiveness (that is, community-based studies; Wade, Worthington, & Vogel, 2007) and dissemination trials that described how a large system of providers might use the treatment effectively with clients in the system (McHugh & Barlow, 2010). An excellent EST would have process-related evidence of the dose-effect relationship, attribute-by-treatment studies that discovered for whom the treatment did and did not work well, and studies of what level and training of therapists could and could not deliver the treatment with expertise and benefit to clients. Excellent EBT are thought to be best practices.

However, even today, EBTs are neither universally embraced (Rotheram-Borus, Swendeman, & Chorpita, 2012) nor are they the end-all in mental health treatment. Yet, as Christian professionals (and ethically-minded lay Christian counselors), we want to provide the best treatment of people who seek our assistance. The best treatment, we think, might be to accommodate secular EBTs to match the beliefs and values of our religious clients. Alternatively, we might develop a therapeutic intervention--perhaps derived from ecclesiastical practice or from an extension of Scripture--and responsibly test it, not merely use it (untested) without worrying about whether it is efficacious, effective, or disseminated with fidelity.

We are all aware of many misuses of well-intentioned and scripturally derived and theologically justified interventions throughout history--such as the dunking test for determination of who was or wasn't a witch. We also are aware that, while Scripture is inspired, our theology is not, and even the most careful theology is subject to error (Worthington, 2010).

In this present article, I aim to suggest ways that a practitioner or clinical researcher could use research on Christian-accommodative psychotherapies to provide a trail for Christian-accommodative practice or clinical research. By the end of this research-into-practice article, the reader should be able to: (a) describe the ways Christian-accommodated treatments are different from and similar to secular counterparts, (b) name six ways to accommodate a secular treatment to Christian clients, and (c) describe evidence one can collect as a clinician (even if one is not a researcher) that can show that a new Christian-accommodated treatment is evidence-based.

I begin with summarizing the current status of research on Christian-accommodative treatments (for a meta-analysis, see Worthington, Hook, Davis, & McDaniel, 2011; for qualitative reviews, see Hook, Worthington, Davis, Gartner, Jennings & Hook, 2010; Worthington, Hook, Davis, Gartner, & Jennings, 2013). I make a practice-friendly yet rigorous critique of the status of the field, noting four critical weaknesses. That leads to recommendations for future research and practice. But this article is about putting the findings of this research and my critique into practice by using it to suggest ways a practitioner or clinical researcher could design or improve the nature of Christian-accommodative interventions.

Worthington's (1994) metaphor of blueprint of a house to represent a treatment approach is too static for our present day. Rather, let me suggest that intradisciplinary integration is more like constructing a mountain trail that moves from valley floor (i.e., the client low point), through the ups and downs of the terrain (i.e., the process of treatment), to mountain peak (i.e., successful termination). While the trail is a prescribed path to the end destination, each hiker has a different experience along the way, wanders back and forth across the trail, backtracks at times, steps off trail at places, and might bushwhack through unknown territory until the trail is intersected higher up. In the end, the destination is to reach the peak, which would correspond to walking with the client to a place of elevated mental health relative to the valley from which the client initiated the journey. The trail is defined by manualized EBTs. However, bushwhacking involves uncharted waters, which might or might not--depending on future research and practice--turn out to be a more efficient and effective route to the peak or to be a snipe hunt.

Evidence for Efficacy of christian Psychotherapy and Recommendations for Researchers and clinicians

Status of the Research

Worthington et al. (2011) meta-analyzed religiously accommodated treatments. Those, in reality, were largely Christian-accommodated, though recently treatments involving Judaism, Islam, and Buddhism have appeared. Worthington et al. compared all research published and non-published with the data for the appropriate comparisons available. Results were stronger for published than non-published studies--like dissertations or "file-drawer studies." Worthington et al. meta-analyzed 51 samples from 46 studies (A = 3,290) that examined the outcomes of religious accommodative therapies and nonreligious spirituality therapies. Comparisons on psychological and spiritual outcomes were made to a control condition, an alternate treatment, or a subset of those studies that used a dismantling design (similar in theory and duration of treatment, but including religious contents). The metric used to describe efficacy in meta-analytic studies is d, the number of standard deviations that a treatment is better than a comparison condition. For psychotherapy, d ~ 0.8 when compared to test-retest conditions.

Worthington et al.'s major findings were several. First, patients in Religious/Spiritual (R/S) psychotherapies showed greater improvement than those in alternate secular psychotherapies both on psychological (d = .26) and spiritual (d = .41) outcomes. Note that the secular treatments already had a d comparable to other secular studies, so the Religious/Spiritual psychotherapies were stronger still! In an ideal case, an alternative secular psychotherapy is the best known treatment for the disorder being studied. In the real world of research, though, clinical researchers might choose an efficacious treatment that might not be the best alternative. Clinical scientists want to show that their treatment is efficacious and they do not want to exert the enormous effort to develop and test a new treatment only to find that an alternative is better. So, in early efforts to investigate new treatments, clinical researchers not surprisingly choose good, but not the best, alternative treatments or compare their new treatment to a test-retest or waiting list condition.

As clinical researchers gain confidence that the treatment is indeed efficacious and better than test-retest-retest (at pre-test, post-test and follow-up), waiting list, or alternative treatments, they test the new treatment against more rigorous comparisons. For Christian accommodative treatments, that rigorous comparison would be against a secular treatment used as the basis to begin the accommodation. So, Christian CBT would likely be compared to secular CBT of equal duration. This is called a dismantling design because the clinical researcher is dismantling the Christian-accommodative treatment into a Christian component and a secular component. However, practically speaking, we observe that if ten hours of total treatment were used, and if two hours of that total involved Christian accommodation, then the secular version actually had two hours more of secular treatment than did the Christian accommodated treatment. It was not, strictly speaking, a dismantling into two components.

When religiously accommodated treatments were compared against secular treatments in a dismantling design, the Christian-accommodative treatments did not perform better than the strictly matched secular treatment on psychological outcomes. Christian-accommodative treatments did outperform alternative treatments on spiritual outcomes (d = .33). The implication is that a Christian psychotherapist could use a Christian-accommodative treatment and say to any client, licensing board, or insurance company, "This treatment is as good as any other treatment for Christian clients on psychological outcomes and better on spiritual outcomes."

Four Weaknesses in the Research

There were many other findings in this meta-analysis. We focus just on those two. But if we critically evaluate the research, we must conclude that it has four major weaknesses.

First, matching the psychotherapist's and client's theology is important. The research is based on Christian clients matched to Christian treatments. We cannot conclude from the research that (a) assigning Christian clients to Jewish, Muslim, or Buddhist treatments would be successful. Also, (b) neither is it good enough to craft a "spiritual" treatment that one hopes to be generically acceptable and expect it to work with a Christian client.

Second, the amount of accommodation was highly variable across studies. A counselor who prays with or for a client once could call the treatment religiously accommodated. A counselor who infused Christian theology and practice in every moment of psychotherapy also has a religiously accommodated treatment. So, what exactly is religiously accommodated treatment? Frankly, we do not know how much, what kinds, and what timing of accommodations make any difference, positive or negative.

Third, the existing research was mostly with theologically conservative clients. We know little about tailoring treatments for theologically moderate, mainline, or liberal clients.

Fourth, most research was on cognitive and CBT psychotherapies, which lend themselves to addressing beliefs and values explicitly. We do not know how Christian accommodation would look in psychodynamic psychotherapy or in other approaches, including explicitly Christian approaches like McMinn and Campbell (2007), unless they are investigated explicitly.

In summary, Christian-accommodated psychotherapy is highly variable. But the integration of Christianity into non-CBT secular theories is probably less explicit than with CBT, which forms the bulk of experimental evidence on which claims of efficacy of Christian accommodation are based.

This summary of the existing research and its limitations leads to recommendations for Christian counselors. (1) Know your clients. Assess with more than the two Level-1 questions (i.e., Are you R/S? Do you think R/S issues might play a role in your problems and their solutions?; Richards & Bergin, 2005). (2) Match to individuals using appropriate tact, timing, and dosage. (3) Being "too religious" can put off even religious clients. (4) Not being religious as much as or how clients expect you to be can put off religious clients. (5) If one is treating mainline Protestant or Roman Catholic or other Christian clients, CBT might not be the most effective. No research evidence exists on what might be effective for non-Evangelical Christian clients, but tentatively one might hypothesize that (a) rituals might be effective; (b) quoting Scripture might not have the same power as with Evangelicals. (6) If one is treating a Pentecostal or Charismatic client, prayer for healing might be expected. The main point is that a Christian psychotherapist might be confident that religiously or spiritually accommodating treatments can improve some outcomes--mental health and especially spiritual outcomes for theologically matched, religiously conservative clients.

Several items must be considered by both Christian practitioners and clinical researchers studying Christian treatments. They must investigate (1) how much and what kinds of discrepancy from client beliefs and values can still produce positive outcomes; (2) how much accommodation is needed for good outcomes; (3) what modifications can cut across religions and spiritualities, and what modifications will be too off-putting. Are there assessments that can help a psychotherapist discern who will and will not be put off by discrepant modifications?

Designing and Disseminating an Evidence-Based Christian-Accommodative Interventions

Beginning where this analysis leaves off, what needs to be done for a practitioner or clinical scientist to design a new Christian-accommodative treatment or shape one for his or her own clientele. I identify five questions that must be answered in designing or accommodating the treatment. Each question has subparts of other questions. My goal is not to provide definitive answers that will identify the ideal Christian-accommodative treatment. I assume that numerous Christian-accommodative treatments might actually fit clients. In fact, I assume that any client might benefit from many secular or Christian-accommodative treatments. It is the questions that are important, and practitioners and clinical scientists must answer them as well as possible with as much objectivity and openness to the Scriptural and psychological evidence as can be mustered.

Question #1--What Is the Problem?

Why would one want to invest the work to create, collect evidence for, and disseminate an evidence-based Christian treatment? Are secular treatments not working? Are one's clients discontented? Are clients leaving counseling or not attending because the psychotherapist is not offering treatment that the clients consider compatible with their Christian beliefs and values? Given that secular treatments tend to work just as well as Christian-accommodative treatments in producing positive client change on psychological outcomes, what specifically is going to be better about the treatment one hopes to create?

Is one's justification the fit to one's clientele? Is it that one's clients find existing treatments offensive or not a religious fit? Is one trying to provide a Christian-accommodative treatment for a disorder that a secular treatment has not been specifically developed to serve or has not been supported with efficacy data?

Question #2--To What Group of Christians Does one Want to Accommodate?

There many approaches to Christianity (Worthington, 2010), and thus many kinds of accommodations a psychotherapist might make if accommodating to serve mostly Evangelicals, Pentecostals/Charismatics, Mainline Protestants, Baptists, Methodists, or Roman Catholics. Or is one trying to develop an approach that would be acceptable to Christians of all denominations? (That is more limiting. One would be doing the equivalent of C. S. Lewis' mere Christianity (Lewis, 1952/2001). Or is one trying to create an approach for R/S clients broadly (or theistic believers; Richards & Bergin, 2005)?

Questions #3--What Psychological Interventions Are Being Adapted?

Are you modifying a secular EBT? A Christian treatment applied to a new population? What school of treatment? Psychodynamic, CBT, interpersonal, couple therapy, integrative behavioral therapy, insight-oriented couple therapy, emotionally focused couple therapy, hope-focused couple approach, family systems therapy, Bowen systems therapy, or forgiveness therapy? One should ask, what special considerations does each approach impose on the counselor? For example, psychodynamic approaches require reluctance in sharing one's beliefs and values. CBT approaches tend to be value-informed and stress rational analysis. Relational or interpersonal therapies tend to see relationships as the cause and solution to problems.

Question #4--How Will One Accommodate?

Recall: This was one of the main critiques of the existing literature. Researchers have not specified how much and what kinds of accommodations they have used. We will consider five areas of accommodation below.

Goals. (1) Do clients get better when measuring the presenting problem? This MUST be a major goal. Psychotherapists are paid or consulted to help people alleviate their symptoms and achieve their goals. If one does not help, then one is not doing Christian treatment. One is just sharing one's Christian philosophy and probably should not be charging for that. (2) Does the client's spiritual life improve? How? How does one know? Are any actual measures of spiritual life employed? (3) Does the client's Christian character improve to be more virtuous, less characterized by vice, more loving, forgiving or self-controlled? How does one know? Has one measured these outcomes? (4) Has the client's personal narrative changed for the better? How does one know? (5) Is one sharing without proselytizing? Imagine that an atheistic therapist who seems opposed to virtually every personal value Christians hold dear is counseling one's son or daughter in the way that one has been counseling regarding Christianity. Would the Christian psychotherapist be pleased?

Concept and worldview. Are one's worldview and concepts worked into treatment, used to enrich treatment, and used in training? Does one have (and provide) materials that reflect one's worldview--for reading (i.e., books for professionals or clients or both, pamphlets, online workbooks, etc.), listening (CDs), or viewing (DVDs, YouTube, websites)? Does one train other intervention providers in one's approach? Does one have manuals that describe treatment in detail (which is an absolute must)? Are training DVDs available?

Rationale for treatment. Is the rationale explicitly worked into treatment? Is it a general rationale to frame the entire approach? Are specific rationales for each technique of intervention included within the approach?

One's theology. How aware is the psychotherapist of his or her theology? To what degree does one believe that one's theology does or does not enter treatment? To what degree is one tolerant of and accepting of different theologies--even when they are radically different from one's own? What does the psychotherapist do if a client expresses an opposing view?

Techniques to include. The fundamental question about Christian accommodation is this: How many and what kind of explicit Christian methods must be worked into a treatment manual (and thus into treatment) before it is considered "Christian accommodative" treatment? In short, exactly what is a Christian accommodative treatment? This question has percolated since the beginning of Christian psychotherapy. People have argued that being a Christian oneself makes a treatment Christian. Others have argued for the use of specific techniques. Biblical counselors have argued that one must be not only a Christian but also a pastor who employs ecclesiastical methods as interpreted within the Reformed Protestant tradition (Adams, 1970). Some require use of Jesus' name, or prayer, or use of Scripture. Often a theorist assumes a particular theology, such as a Protestant Evangelical or fundamentalist theology (Coe & Hall, 2010; Johnson, 2007). There are, of course many variants of these positions (Johnson, 2010). But once a psychotherapist selects a position, the universe of methods that can be employed is set, even though there are many choices of methods and techniques within the universe of methods.

Specific Techniques. Aligned with one's goals, worldview, rationale for treatment, and universe of methods, one must choose one's specific techniques. These will balance a variety of factors, which might include the secular counseling approaches and techniques one prefers, the research on a particular disorder that might suggest a particular evidence-based treatment for a particular disorder, the ecclesiastically and theologically derived techniques the psychotherapist and the client are both comfortable with, and the client's objectives and goals (i.e., whether the client prefers a quick problem-focused treatment or more personally explorative treatment).

However, as psychotherapists in actual practice know, decisions involve many intangibles--often ones we prefer not to acknowledge even to ourselves. I am convinced that almost no Christian psychotherapists consciously makes Machiavellian choices like I am about to mention. Yet, of all people, Christian psychotherapists know that our hearts are desperately wicked, even in a redeemed state. Cognitive psychologists (Kahneman, 2011) as well as psychoanalytically informed psychotherapists (i.e., Coe & Hall, 2010) tell us that many of our decisions are not fully rational. Thus, in spite of our best intentions and efforts, we might make decisions about techniques and even about whether to accept clients based on things like whether we like the client or find a particular person irritating or frustrating, whether we believe we are likely to help the client, the extent of our training in particular evidence-based and non-evidence-based treatments that seem appropriate for the client, and other harsher realities or real-life human (i.e., subject to the fall) weaknesses. Those unseemly weaknesses include, if we are honest with ourselves, personal preferences and biases. Perhaps we don't like and over the years have found that we do not work very well with superior-acting rich and entitled clients, earthy red-neck clients, other clients that we have been trained to and try hard to treat just as fairly as all of our other clients. The more unseemly side of practice also includes the financial state of the economy (in hard times, or if we have openings in our schedule, we might take clients that we know (but are reluctant to admit to ourselves) that we will not counsel as well as we counsel others. We might take on or refuse clients or we might select techniques that are aimed at short-term symptom relief (or at long-term growth and exploration) for other mundane reasons, such as whether we are planning a vacation in two months, the relationships with the client's insurance provider, and many other aspects of the darker side of treatment decision-making. Our choices of techniques and of which clients we might agree to work with often are based on realities and often take place outside of conscious awareness.

Thus, we clearly want to decide rationally whether we will employ explicitly Christian techniques, like prayer for the client between sessions, prayer with the client in session, reading the Bible in session or assigning Bible reading between sessions, exegesis of Scriptural passages that the client does not understand and are relevant to his or her problems, whether we justify interventions and conceptualizations with Scripture, whether we deal with direct questions regarding theology or God (e.g., Where was God when my child was killed by a drunk driver?), how we deal with anger or disappointment with God when it arises, whether we feel that we are receiving confession and offering absolution (or point the person to a priest or pastor), whether we help to connect the client with a church, church services, or even pastoral counseling, how we deal with a client's sense of desecrations or sacred losses, whether and how we provide counsel when something in the church is the problem (e.g., fallen pastor, church split, person in leadership not respecting one, hurt by fellow congregant) and that is especially true if we have a formal connection with the church in question. As I have observed earlier, the fundamental question about Christian accommodation is this: How many and what kind of explicit Christian methods must be worked into a treatment manual (and thus into treatment) before it is considered "Christian accommodated" treatment?

Can the answer to this be different for different clients? How do we decide? We might use a treatment manual (recommended for EBTs), but does a manual stifle the creativity of counseling? Does a manual cover the important decisions of treatment?

Question #5--How Will You Show Your Treatment Works?

Standards of practice today mandate that we use as many EBTs as possible. That suggests that we adduce evidence of the treatment's efficacy and effectiveness as it is being employed on the ground. In contrast to the early years of psychotherapy research that seemed only to value the publicly vetted (in scientific journals) randomized clinical trial (RCT) performed in a variety of independent labs, EBT admits more different types of research in support of efficacy and effectiveness of treatments. Still, the RCT is the acknowledged gold standard. We are encouraged to provide as many types of research in support of an EBT as we can. These can include many types of evidence that individual practitioners can provide.

Case studies are useful after the initial formation of a treatment. They encourage practitioners to adduce other types of evidence.

The next step in rigor is the N = 1 design. These examine individual cases, as case studies do; but, they collect data on outcomes. Rather than merely provide data on symptom relief, the best efforts use multiple baselines. Multiple baseline designs are easily done by the average practitioner committed to EBT. For example, a psychotherapist who uses mostly cognitive and interpersonal methods might use at intake three brief measures--of dysfunctional thinking, troublesome behavior, and forgiveness. Those might be re-administered at the end of different phases of treatment. The client is expected to make gains appropriate to the focus of treatment. Such a design helps the psychotherapist be assured that the specific treatment is producing desired effects, not merely improving the client's global mood. Thus, psychotherapists who wished to use N = 1 multiple-baseline treatments would analyze their approach to determine the usual components of treatment so that those could be assessed throughout treatment.

Repeating the N = 1 multiple-baseline design with say 10 clients would be even better. Of course, one would not be content to use a single client to provide the full evidential base. Rather, one would want to repeat the design to make sure that it worked for many clients.

Wait list designs can be employed to conduct a single-practitioner RCT. One might pair two clients and randomly assign them to immediate treatment or waiting list. The key to this design is to assess both members of the pair at the same time points. Even if the waiting period was two or three weeks, the waiting period could allow the psychotherapist to infer that treatment was responsible for improvement, not the mere passage of time. This could be paired with a multiple baseline design in which two components of treatment typically followed each other (let's call them X and Y). The clients received the two assessment instruments at each observation period (designated O) about two weeks apart. The design for the two clients would look like this:

O   X   O   Y   O       O
O       O   X   O   Y   O

If the practitioner collected five pairs of clients, using this design, the researcher could not only say that treatment component X and Y were having their desired effects, but also that time was not a factor because the immediate treatment client was improving more when getting treatment X than the waiting client and the waiting client was improving more on measure Y than was the immediate treatment client who had already received treatment Y.

Conclusion

In the present article, we have not looked at a particular research study or topic and asked how to put those findings into practice. Rather, we have examined a meta-analysis of religious and spiritual accommodation of treatments to like-minded clients. We have tried to rigorously analyze the weaknesses of this research and draw practical lessons that an individual practitioner might use to (a) devise the strongest Christian-oriented treatment possible for his or her clientele and (b) provide an evidential basis for his or her Christian accommodative treatments.

Frankly, the stakes have gone up in doing Christian accommodative treatments. No longer can we sit in our armchair with our theoretical book on CBT, our Bible, and our knowledge of Christian pastoral care treatments and design a blueprint for accommodating our treatments (see Worthington, 1994). Now, the standards of our profession--if we are to subject ourselves to a state license to practice clinical psychology or be a licensed professional counselor--demand that we consider research evidence and do our best to assure our clients, third-party payers, and state licensing boards that we are counseling responsibly (see Tan, 2011). This is more like constructing a well-engineered trail to the top of a mountain than constructing a house. We must construct a plan for a journey instead of designing a resting place. I hope that this article helps you construct an efficient and flexible trail that will lead your clients out of their valleys toward the mountain top while allowing them to have their own off-trail experiences.

References

Adams, J. (1970). Competent to counsel. Grand Rapids, MI: Zondervan.

American Psychological Association. (2005). Policy statement on evidence-based practice in psychology. Washington, DC: Author. Retrieved from http://www.apa.org/practice/ebp.html on October 5, 2012.

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7-18.

Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review Psychology, 52, 685-716.

Chambless, D. L., Sanderson, W. C., Shoham, V., Bennett-Johnson, S. B., Pope, K., Crits-Christoph, et al. (1996). An update on empirically validated therapies. Clinical Psychologist, 49, 5-18.

Coe, J. H., & Hall, T. W. (2010). Psychology in the Spirit: Contours of a transformational psychology. Downers Grove, IL: InterVarsity Press.

Hook, J. N., Worthington, E. L., Jr., Davis, D. E., Gartner, A. L., Jennings, D. J. II., & Hook, J. P. (2010). Empirically supported religious and spiritual therapies. Journal of Clinical Psychology, 66, 46-72.

Johnson, E. L. (2007). Foundations for soul care: A Christian psychology proposal. Downers Grove, IL: InterVarsity Press.

Johnson, E. L. (Ed.). (2010). Psychology and Christianity: Five views. Downers Grove, IL: InterVarsity Press.

Kahneman, D. 2011. Thinking, fast and slow. New York, NY: Farrar, Straus, Giroux.

Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63, 146-159.

Lewis, C. S. (1952/2001). Mere Christianity. A revised and amplified edition. New York, NY: Harper-Collins.

McCullough, M.E. (1999). Research on religion-accommodative counseling: Review and meta-analysis. Journal of Counseling Psychology, 46, 92-98.

McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-based psychological treatments: A review of current efforts. American Psychologist, 65, 73-84.

McMinn, M. R., & Campbell, C. D. (2007). Integrative psychotherapy: Toward a comprehensive Christian approach. Downers Grove, IL: InterVarsity Press.

Richards, P. S., & Bergin, A. E. (2005). A spiritual strategy for counseling and psychotherapy (2nd ed.). Washington, D. C.: American Psychological Association.

Rotheram-Borus, M. J., Swendeman, D., & Chorpita, B. F. (2012). Disruptive innovations for designing and diffusing evidence-based interventions. American Psychologist, 67, 463-476.

Tan, S. Y. (2011). Counseling and psychotherapy: A Christian perspective. Grand Rapids, MI: Baker Academic.

Wade, N. G., Worthington, E. L., Jr., & Vogel, D. L. (2007). Effectiveness of religiously tailored interventions in Christian therapy. Psychotherapy Research, 17, 91-105.

Worthington, E. L., Jr. (1994). A blueprint for intradisciplinary integration. Journal of Psychology and Theology, 22, 79-86.

Worthington, E. L., Jr. (2010). Coming to peace with psychology: What psychological science tells us about Christianity. Downers Grove, IL: InterVarsity Press.

Worthington, E. L., Jr., Hook, J. N., Davis, D. E., Gartner, A. L., & Jennings, D. J., II. (2013). Conducting empirical research on religiously accommodated treatments.

In Kenneth I. Pargament (Ed.-in-Chief), A. Mahoney, & E. Shafranske (Assoc. Eds.), APA handbooks in psychology: APA handbook of psychology, religion, and spirituality (Vol. 2, pp. 651-669). Washington, DC: American Psychological Association.

Worthington, E. L., Jr., Hook, J. N., Davis, D. E., & McDaniel, M. (2011). Religion and spirituality. Journal of Clinical Psychology: In Session, 68, 204-214.

Worthington, E. L., Jr., Kurusu, T. A., McCullough, M. E., & Sandage, S. J. (1996). Empirical research on religion and psychotherapeutic processes and outcomes: A 10-year review and research prospectus. Psychological Bulletin, 119, 448-487.

Everett L. Worthington, Jr.

Virginia Commonwealth University

Correspondence regarding this article should be addressed to Everett L. Worthington, Jr., Ph.D., Department of Psychology, Virginia Commonwealth University, Box 842018, Richmond, VA 23284-2018; eworth@vcu.edu.

Everett L. Worthington, Jr., is Professor of Psychology at Virginia Commonwealth University. His research interests are forgiveness, marriage dynamics and enrichment, and religious and spiritual beliefs and values.