Christian approaches for helping couples: review of empirical research and recommendations for clinicians 9.

Hook, Joshua N. ; Worthington, Everett L., Jr. ; Ripley, Jennifer S. 等

Several Christian approaches are available to help couples who are having relationship problems (Worthington, 1996). Indeed, Christian couple therapy and enrichment are popular and widely practiced, with many Christian therapists seeing large numbers of couples each year (Hook & Worthington, 2009). Furthermore, numerous Christian approaches exist to help couples prepare for marriage (e.g., Combs, Bufford, Campbell, & Halter, 2000; Ripley, Parrott, Worthington, & Parrott, 2000; Trathen, 1995).

Although many words have been written describing and extolling approaches to Christian couple therapy and enrichment, historically there has been little effort to examine these approaches empirically (Hook & Worthington, 2009; Ripley & Worthington, 1998). Indeed, in their review on Christian couple therapy, Ripley and Worthington (1998) reported that empirical research on Christian couple therapy was virtually nonexistent, and they called for more research in this area. In the past decade, the research base on Christian couple therapy and enrichment has slowly developed. Furthermore, there has also been an increase in research on religious therapy in general (Worthington, Hook, Davis & McDaniel, 2011), and these findings aid our understanding of Christian couple approaches. Thus, the purpose of the present article is to review recent empirical research on Christian couple therapy and enrichment and to offer suggestions for researchers and clinicians based on these findings. First, we define Christian couple therapy. Second, we briefly review the empirical research on religious therapy in general and then Christian couple therapy and enrichment specifically. Finally, we offer suggestions for researchers and clinicians.

What Is Christian Couple Therapy?

Defining Christian couple therapy has not been easy (McMinn, Staley, Webb, & Seegobin, 2010). One stumbling block to agreement is that researchers and clinicians might differ in their opinions of the minimum requirements of couple therapy to qualify as "Christian." For example, if the therapist is a Christian, does that make the couple therapy "Christian," regardless of the faith commitment of the couple? What if one partner is a Christian, but the other partner is not? Do Christian faith commitments of the therapist and couple provide the minimum requirements to make the couple therapy "Christian," or must religious techniques such as prayer or references to Scripture be present to make a couple therapy "Christian?" These questions are especially important in research settings in which different types of therapies are compared with each other.

Ripley and Worthington (1998) identified four uniquely Christian themes that are often present in Christian couple therapy. First, Christian couple therapists often emphasize Christian marriage as a covenant instead of a contract. Viewing marriage as a covenant emphasizes individual sacrifice, commitment, vow-taking, treating the couple as the primary unit of the marriage, and using spiritual interventions to restore relational order (Ripley, Worthington, Bromley, & Kemper, 2005). Viewing marriage as a contract, on the other hand, emphasizes each partner's self-actualization, negotiation between separate parties, mutual agreement of individuals, seeing the individual as the primary unit of the marriage, and using psychological (rather than spiritual) interventions to restore relational order (Ripley et al., 2005). Second, Christian couple therapists often rely on God in the person of the Holy Spirit to empower change in couples and appeal to the active work of the Holy Spirit as the causal agent to whom change is attributed (Prest & Keller, 1993). Obviously, any overt verbal reference to the work of the Holy Spirit will be highly dependent on the theology of the counselor and couple. For example, in Pentecostal and Charismatic theological approaches, the Holy Spirit is often discussed more explicitly than in Evangelical, mainline Protestant, and traditional Roman Catholic approaches. Third, Christian couple therapists often note that problems occur in troubled relationships because partners are sinful (Worthington, 1994). Sin often shows up in relationships as conflict, hurt, and woundedness. Forgiveness is considered an important way to help couples deal with hurts (Worthington & DiBlasio, 1990). Couples are encouraged to experience Divine forgiveness for personal sin and to extend forgiveness to their partner through the power of the Holy Spirit. Fourth, Christian couple therapists often view couple growth and spiritual growth as closely linked (Worthington, 1990; Wurster, 1983).

In previous research on the prevalence of explicitly Christian couple therapy, Hook and Worthington (2009) defined Christian couple therapy as (1) therapy by a professing Christian therapist that (2) involves both partners (3) who profess to be Christians and also that (4) addresses Christian values or issues explicitly at least once during therapy. Thus, Hook and Worthington differentiate Christian therapy from (a) virtuous therapy, where positive humanistic virtues would be the foundation, (b) other types of religious therapy (e.g., Muslim, Jewish), or even from (c) spiritual therapy, which might explore spiritual concepts without situating counseling within a particular religious tradition.

In some ways, this definition is rather narrow in that Christian couple therapy requires the therapist and both partners identify as Christian. Generally, we have considered it ethically questionable to offer explicitly religious elements when either partner was not a Christian. There are, of course, gray areas with that formulation--such as offering Christian interventions after consenting a non-Christian client or offering Christian interventions if both partners explicitly say that a technique is desired. However, there is certainly a danger that a non-Christian partner may feel coerced if the Christian partner and the couple therapist advocate for Christian methods. Furthermore, any time that partners disagree on methods, the possibility exists that an intervention will simply not be efficacious--regardless of whether it is used ethically.

The Effectiveness of Religious Therapy

We begin our review of the effectiveness of Christian couple therapy by broadening our review to examine the effectiveness of religious therapy generally. Over the recent decade, the number and methodological rigor of outcome studies examining religious therapy has increased, allowing for a more complete and precise review of the research in this area (Worthington et al., 2011). Indeed, there have been several recent reviews and meta-analyses on religious and spiritual therapies (Hook et al., 2010; McCullough, 1999; Richards & Worthington, 2010; Smith, Bartz, & Richards, 2007; Worthing ton et al., 2011).

In general, the majority of individual studies comparing religious therapies with non-religious therapies have found that participants in most explicitly religious therapies improve as well as (but not better than) participants in non-religious therapies (McCullough, 1999; Hook et al., 2010).

This result has been found across a wide variety of presenting problems and religious affiliations, although the majority of research has been conducted on Christian therapies or therapies that use a general spirituality. However, as the number of studies has increased, two recent meta-analyses (Smith et al., 2007; Worthington et al., 2011) have found that participants in religious therapies reported more improvement than did participants in non-religious therapies. Meta-analyses combine effect sizes across several studies; thus, they are more powerful to detect differences between conditions than are individual studies. In recent years, the number of studies being analyzed has also increased, increasing the power to detect small but relatively consistent differences.

Worthington et al. (2011) also analyzed a smaller subset of comparisons (11 of 51) that compared religious therapies to a secular therapy of the same (a) duration and (b) theoretical orientation (called a dismantling design). In this subset of studies, participants in religious therapies reported equivalent improvement on psychological outcomes (e.g., depression) as did participants in non-religious therapies. However, participants in religious therapies reported greater improvement on spiritual outcomes (e.g., spiritual well-being) than did participants in nonreligious therapies.

Worthington et al. (2011) offered several implications for clinical practice based on their review of research. First, they noted that religious therapy works and should be viewed as a valid treatment option for religious clients. Second, they reported that there is at present not strong evidence that the addition of religion to therapy can reliably improve psychological outcomes in individual therapy. Third, they noted that religious therapies offer spiritual benefits not found in non-religious therapies, and should be considered the treatment of choice if spiritual outcomes are highly valued. Fourth, they advised that the inclusion of religion into therapy should follow the needs and desires of particular clients.

The Effectiveness of Christian Couple Therapy

We now review the studies that have empirically examined a specifically Christian approach to couple therapy or enrichment (see Table 1). We found twelve empirical studies involving Christian couple treatments. One study conducted a survey of Christian couple therapists. Three studies examined Christian couple therapy. Eight studies examined Christian premarital or marital enrichment.

Survey of practicing Christian couple counselors. One study (Hook & Worthington, 2009) surveyed Christian couple therapists from the American Association of Christian Counselors, which is a professional organization of about 30,000 therapists whose practices are informed by a Christian worldview. Participants included 630 professional, pastoral, and lay therapists. Christian couple therapy was widely practiced, with large numbers of couples seen each year (on the average, 22 per year by professionals, 16 per year by pastoral counselors, and 6 by lay counselors). Professional and pastoral counselors saw almost all of the couples conjointly (about 87 percent). Christian couple therapists generally had positive attitudes toward incorporating religious techniques into therapy, although therapists with higher levels of religious commitment had more positive attitudes than did those with lower religious commitment. In about three-fourths of couple cases, therapists reported dealing explicitly with Christian issues. Couple therapists were influenced by both Christian and secular theories of couple therapy. Overall, there were several differences between professional, pastoral, and lay therapists (e.g., years of experience, religious commitment, attitudes toward inclusion of religion into therapy, influence of Christian vs. secular theories).

Christian couple therapy. Three studies (Hook, Worthington, Davis, & Atkins, 2011; Ripley et al., 2008; Ripley et al., 2010) examined Christian couple therapy. Two studies (Ripley et al., 2008; Ripley et al., 2010) were efficacy studies that examined Christian and non-Christian versions of Hope-focused marital therapy (Worthington, 2005; Worthington, Ripley, Hook, & Miller, 2007). Hope-focused marital therapy is a brief, strategic approach to couple therapy that works to promote faith, hope, and love in the couple relationship. In these two clinical trials, couples (random assignment n = 43; client selected n = 80) who attended explicit Christian hope-focused marital therapy (i.e., an approach in which the use of religious practices were agreed up on at beginning of treatment) reported similar relationship improvements as did couples (random assignment n = 32; client selected n = 28) who attended implicit hope-focused marital therapy (i.e., no explicitly religious practices were agreed upon nor offered). This finding was consistent regardless of whether couples were randomly assigned to conditions or were allowed to choose the extent to which religious elements were included in therapy. Thus, research evidence supports the use of Christian hope-focused marital therapy, although--like most of the findings in the early investigation of religious and spiritual interventions for individual counseling--the religious version of this program does not appear to result in improved relationship outcomes relative to the non-religious version. However, it should be noted that most of the clients in this study were Christians themselves (94%), and all of the therapists self-identified as Christian. If clients brought anything religious to discuss in treatment, the therapist responded in a Rogerian type of reflection and then moved forward with treatment. While this style of response might not be enriched beyond basic accommodation of religion, it was still accommodating religion on a basic level.

The third study examining Christian couple therapy (Hook et al., 2011) was a field study that did not specify the theory or type of couple therapy conducted. In it, Hook et al. (2011) identified therapists in practice who were members of the AACC or CAPS. Volunteer therapists (n = 44) identified the next one or two Christian couples requesting Christian couple therapy (n =68 couples, n =136 individuals) and put those couples in contact with the researchers. The researchers surveyed the clients about their experiences in therapy at the 1st, 4th, and 8th sessions. Religious techniques, such as prayer or use of Scriptures, were each used in about half the sessions. The use of religious techniques was predicted by the religious commitment of the clients, which may indicate that Christian therapists are tailoring their use of religious techniques based on the religious commitments and desires of individual couple clients. In general, couple therapy was effective as evidenced by (a) improved relationship satisfaction and working alliance with the therapist over time, and (b) high levels of satisfaction with therapy. The use of explicitly religious techniques did not reliably predict improvement in therapy.

Christian couple enrichment for premarital or married couples. Eight studies (Combs et al., 2000; Hook, Worthington, Hook, Miller, & Davis, in press; Laurenceau, Stanley, Olmos-Gallo, Baucom, & Markman, 2004; Noval, Combs, Wiinamaki, Bufford, & Halter, 1996; Ripley et al., 2000; Ripley et al., 2002; Trathen, 1995; Wong, 2005) examined Christian couple enrichment, either for premarital or marital couples. Although all studies evaluated couple enrichment, the programs evaluated varied. The Combs et al. (2000) and Noval et al. (1996) studies evaluated a cognitive-behavioral intervention called "Traits of a Happy Couple"; the Ripley et al. (2000) study evaluated the Parrotts' Saving Your Marriage Before It Starts (SYMBIS) workshop; the Ripley et al. (2002) study evaluated hope-focused enrichment; the Laurenceau et al. (2004) and Trathen (1995) studies evaluated PREP, which is a skill-based intervention that targets communication and conflict resolution skills; and the Hook et al. (in press) and Wong (2005) studies evaluated church-based premarital programs.

Six studies (Combs et al., 2000; Hook et al., in press; Laurenceau et al., 2004; Noval et al., 1996; Ripley et al., 2000; Ripley et al., 2002) reported that couples attending the intervention improved over time, whereas the other two studies (Trathen, 1995; Wong, 2005) did not. These negative results, however, should be taken with caution. The Wong (2005) study was somewhat underpowered and evaluated only 9 couples. Couples showed some improvement on most dependent variables, although in most cases these improvements were not significant. The Trathen (1995) study evaluated Christian PREP (Stanley & Trathen, 1994), which is based on the PREP program (Markman, Renick, Floyd, Stanley, & Clements, 1993), which has been found to meet the standards to be an empirically supported treatment (Jakubowski, Milne, Brunner, & Miller, 2004).

In sum, the research on Christian couple therapy is still in its infancy, although the results of initial studies are positive. The Christian hope-focused approach to couple therapy has been shown to be as effective as the secular version of this approach. Furthermore, an observational study of Christian couple therapy has shown that Christian couple therapy generally results in positive outcomes for most clients. The research base on Christian couple enrichment is more highly developed. Two secular versions of couple enrichment that have been designated as empirically supported (PREP and Hope-focused) have Christian versions. Furthermore, most studies on other Christian versions of couple enrichment programs have shown positive results for couples.

Recommendations for Researchers

Based on the brief review of research on religious therapy in general and Christian couple therapy specifically, we offer several suggestions for researchers. First, for those interested in conducting outcome research, Christian couple therapy is a field that is full of promise. There are several approaches to Christian couple therapy that have little or no research support (Ripley & Worthington, 1998). Lack of empirical support raises several ethical and practical issues for Christian therapists. First, professional and Christian ethics exhort therapists to use therapies and techniques that are supported by research. Second, insurance companies may not reimburse for treatments without sufficient empirical support. Thus, if Christian therapists would like to continue to offer Christian couple therapy, it is crucial that researchers continue to progress the state of the field.

In addition to conducting further outcome studies, Christian couple researchers must push forward the thinking about the integration of religion and therapy. Most studies have found that religious therapies perform about as well as non-religious therapies (with perhaps a small advantage for spiritual outcome variables). In addition to conducting outcome studies, researchers must study the aspects of religion in therapy or religiosity in individuals that contribute to effective therapy. For example, we have hypothesized that religious therapies are more effective for those with high levels of religious commitment (Worthington et al., 2011), but this hypothesis has received mixed support. Some findings that have not supported this hypothesis have caused us to think that there may be aspects to individuals who are very highly religious that actually contribute to worse outcomes in therapy (e.g., rigidity in thinking). We might amend this hypothesis by predicting that religious therapies will be more effective for those with low levels of acculturation to mainstream values. Matching by race/ethnicity and language has proven important for clients with low acculturation. We suggest that there may be parallels with religious diversity, such that clients who are not well acculturated into mainstream values may not attend and may have difficulty benefiting from secular therapies. Other areas for future research include (a) the effectiveness of specific religious techniques on therapeutic outcomes, (b) religious match/mismatch between client and therapist, and (c) the types of training therapists need to effectively and ethically conduct Christian couple therapy.

There are certain issues to consider when conducting research on Christian couple therapy specifically. First, in a survey of Christian couple therapists, several differences were found between professional, pastoral, and lay therapists. However, the majority of research on the effectiveness of Christian couple therapy has focused on the setting of professional therapy. More research must be conducted on pastoral and lay therapy, as these are important avenues for which Christian couples are receiving help. Second, more research must be conducted with couples for whom religion is a salient issue in therapy. The religious homogamy (i.e., shared affiliation) of couples has been found to be positively associated with relationship satisfaction (Mahoney, Pargament, Tarakeshwar, & Swank, 2001). Furthermore, in a study of couple therapy, couples with large differences in religious commitment reported lower levels of relationship satisfaction at the beginning of therapy, but by the end of therapy this difference had disappeared (Hook et al., 2011). Perhaps these differences were able to be worked through and discussed with a religiously-sensitive couple therapist.

We have defined Christian couple therapy to involve four characteristics: (1) therapy by a professing Christian therapist that (2) involves both partners (3) who profess to be Christians and also that (4) addresses Christian values or issues explicitly at least once during therapy (Hook & Worthington, 2009). It is necessary to make such strict definitions for the sake of scientific study of a phenomenon. However, it is clear that much therapy by Christian couple therapists might involve only one partner who is a Christian or might involve partners who disagree about their faith. Also, much of explicit Christian therapy might not address explicitly Christian topics. More research is needed about situations which may not meet our strict criteria for Christian couple therapy.

Little research was considered in the present review that involved group therapy, yet workshops, small groups, psychoeducational interventions, and Christian education classes can all have substantial effects on Christian couples. In addition, it appears that more Christian couples are deciding to cohabitate before marriage. Research is necessary to examine the similarities and differences between these types of couples, and how they respond to therapy.

Recommendations for Clinicians

On one hand, clinicians should feel confident that Christian couple approaches have evidence supporting their effectiveness. Although there are relatively few empirical studies examining Christian couple therapy and enrichment, most of the research has shown these approaches to be as effective but not more effective that secular approaches. This also coincides with the majority of the research on religious therapy which has found that religious therapies are as effective as equivalent non-religious techniques for religious individuals. Thus, even if there is no empirical evidence for a particular approach to Christian couple counseling or enrichment, we suggest that clinicians can justify their use of Christian approaches that are based on a secular couple therapy or enrichment approaches that is supported by evidence (couple therapies: behavioral couple therapy, cognitive-behavioral couple therapy, insight-oriented couple therapy, emotion-focused couple therapy; Baucom, Shoham, Mueser, Daito, & Stickle, 1998; couple enrichment: PREP, relationship enhancement, couple communication program, hope-focused; Jakubowski et al., 2004). On the other hand, in a field that both ethically and financially tied to being able to demonstrate effectiveness, it is crucial that this field continue to grow and accelerate.

Conclusion

Although Christian approaches for helping couples are common and popular, historically these approaches have lacked empirical support. This body of literature has begun to grow, both for religious therapies in general and Christian couple approaches in particular. In general, although sparse, evidence has shown that religious therapies and Christian couple approaches are about as effective as non-religious approaches, and may offer some spiritual benefits not found in nonreligious approaches.

References

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Joshua N. Hook

University of North Texas

Everett L. Worthington, Jr.

Virginia Commonwealth University

Jennifer S. Ripley

Regent University

Don E. Davis

Georgia State University

The authors would like to thank the American Association of Christian Counselors Foundation for funding a portion of the present research in a grant to the third author. Correspondence regarding this article should be addressed to Joshua N. Hook, Ph.D., University of North Texas, Department of Psychology, 1155 Union Circle #311280, Denton, TX 76203; joshua.hook@unt.edu.

Authors

Joshua N. Hook is Assistant Professor of Psychology at the University of North Texas. His research interests include forgiveness, humility, religion/spirituality, multicultural counseling, couple therapy, and treatments for alcohol dependence and hypersexuality.

Jennifer S. Ripley is Professor of Psychology and PsyD Program Chair at Regent University. Her research is in religion and couples dynamics and treatment.

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.

Don E. Davis is Assistant Professor of Psychology at Georgia State University. His research interests include forgiveness, humility, religion/spirituality, multicultural counseling, and couple therapy.

Table 1

Summary of empirical studies examining Christian couple therapy
and enrichment

Study                  Participants         Treatment Studied

Combs et al. (2000)    31 couples from      Traits of a Happy Couple
                       community Majority   Enrichment
                       were married

Hook & Worthington     630 members of       N/A
(2009)                 AACC Professional,
                       pastoral, and
                       lay counselors

Hook et al. (2011)     731 first--time      Marriage Matters
                       attendees at         Church-based
                       workshop             Enrichment

Hook et al. (2011)     68 couples from      Christian approach
                       community            Therapy
                       89% married

Study                  Participants         Treatment Studied
Laurenceau et al.      217 couples from     Christian PREP
(2004)                 community. Engaged   PREP
                       or actively          Enrichment
                       planning wedding

Noval et al. (1996)    290 couples from     Traits of a Happy Couple
                       community            Enrichment

Ripley et al. (2000)   402 individual       SYMBIS
                       Pre--marital or      Enrichment
                       newly married

Ripley et al. (2002)   14 couples from      HOPE
                       community            Enrichment (assessment
                                            and feedback only)

Study                  Participants         Treatment Studied
Ripley et al. (2008)   75 couples from      HOPE
                       community            Therapy

Ripley et al. (2010)   108 couples from     HOPE
                       community            Therapy

Trathen (1995)         77 premarital        Christian PREP
                       couples from         Enrichment
                       community

Wong (2005)            9 couples from       Church-based
                       community            Enrichment
                       78% engaged

Study                  Design

Combs et al. (2000)    Random assignment
                       to 1 of 2 conditions:
                       Traits of a Happy Couple
                       Control
                       Assessment at
                       pretest, posttest, and
                       6 mo. follow-up

Hook & Worthington     Cross-sectional,
(2009)                 correlational design

Hook et al. (2011)     One-group, posttest
                       only design

Hook et al. (2011)     One-group,
                       longitudinal design
                       Assessment at sessions
                       1, 4, and 8

Study                  Design
Laurenceau et al.      Random assignment
(2004)                 to 1 of 3 conditions.
                       PREP by religious
                       organization
                       PREP by secular
                       counselors
                       Treatment as usual
                       Assessment at pretest,
                       posttest, and 1 year
                       follow-up

Noval et al. (1996)    Quasi-experimental design
                       Church group
                       Non-church group
                       Assessment at pretest and
                       and posttest

Ripley et al. (2000)   Quasi-experimental
                       design
                       Poor baseline dyadic
                       adjustment
                       Good baseline dyadic
                       adjustment
                       Assessment at pretest,
                       post-test and 1 month
                       follow-up

Ripley et al. (2002)   Random assignment to
                       1 of 2 conditions.
                       HOPE
                       Control
                       Assessment at pre-test,
                       post-test and 1 month
                       follow-up

Ripley et al. (2008)   Random assignment to
                       1 of 2 conditions:
                       Religious HOPE
                       Non-religious HOPE
                       Assessment at pretest,
                       posttest, and 6 mo.
                       follow-up

Ripley et al. (2010)   Non-random assignment
                       to 1 of 2 conditions:
                       Religious HOPE
                       Non-Religious HOPE
                       Assessment at pretest,
                       posttest, and 6 mo.
                       follow-up

Trathen (1995)         Random assignment to
                       1 of 3 conditions:
                       Christian PREP
                       Christian Information
                       Control
                       Assessment at pretest
                       and posttest

Wong (2005)            One-group,
                       longitudinal design
                       Assessment at pretest
                       and posttest

Study                  Main Findings

Combs et al. (2000)    Participants in the Traits of a Happy Couple
                       condition reported greater improvement in
                       relationship--satisfaction than did
                       participants in the control condition.

Hook & Worthington     Couple therapy is popular and large numbers of
(2009)                 couples are seen each year.
                       Christian couple therapists are highly
                       committed to their religion.
                       Religious techniques are viewed as appropriate
                       for use in Christian couple therapy.
                       Religiosity of therapist predicts viewing
                       religious techniques as appropriate.
                       Christian couple therapists are influenced
                       by both Christian and secular theories of
                       couple therapy. There are several differences
                       between professional, pastoral, and lay
                       therapists.

Hook et al. (2011)     Participants reported a high level of
                       satisfaction with the workshop.
                       Participants reported that their marriage had
                       improved from before to after the workshop.

Hook et al. (2011)     Religious techniques such as prayer were each
                       used in about half the sessions.
                       Religiosity of the client predicted the use of
                       religious techniques.
                       Couples improved over time in relationship
                       satisfaction and working alliance with the
                       therapist. Couples reported high levels of
                       satisfaction with therapy. The use of
                       religious techniques did not reliably predict
                       improvement in therapy.

Laurenceau et al.      No difference in overall marital satisfaction
(2004)                 across conditions.
                       There were some changes in behavior and
                       communication that favored participants who
                       received PREP by religious organizations.

Noval et al. (1996)    Overall participants improved over time in
                       relationship satisfaction.
                       No difference in improvement between church
                       participants and non-church participants.

Ripley et al. (2000)   Overall participants improved over time in
                       relationship satisfaction and intimacy.
                       Participants with poor baseline dyadic
                       adjustment showed greater improvement than did
                       participants with good baseline dyadic
                       adjustment.

Ripley et al. (2002)   Most participants improved by self-report
                       (22 individuals) with 10 individuals reporting
                       improvement of more than one standard
                       deviation on the primary measure of
                       relationship functioning. The control group
                       was then given the assessment and feedback
                       intervention and used for the reporting of
                       case data. There was no difference
                       between control and treatment
                       on this small pilot study.

Ripley et al. (2008)   There was no difference in improvement between
                       the Religious HOPE and Non-religious HOPE
                       conditions. Both treatment conditions showed
                       significant improvements in relationship
                       satisfaction and forgiveness across time with
                       effect sizes in the large range.
                       There was no difference in commitment, heart
                       rate, or blood pressure between the conditions.

Ripley et al. (2010)   There was no difference in improvement between
                       the Religious HOPE and Non-religious HOPE
                       conditions. Both treatment conditions showed
                       improvement on relationship satisfaction,
                       forgiveness, and communication skills with
                       large effect sizes.

Trathen (1995)         There was no difference in relationship
                       satisfaction between the three conditions.
                       There was no difference in communication
                       between the three conditions.
                       Participants in the Christian PREP and
                       Christian Information conditions reported
                       greater confidence compared to participants in
                       the control condition.

Wong (2005)            Participants improved in topical knowledge and
                       religious well-being. Participants did not
                       improve in relationship satisfaction
                       or communication.