The effects of a manualized group-psychotherapy intervention on client God images and attachment to God: a pilot study.

Thomas, Michael J. ; Moriarty, Glendon L. ; Davis, Edward B. 等

The goal of this pilot study was to examine the effects of an 8-week, manualized, outpatient group-psychotherapy intervention on client god images and attachment to God. Participants were 26 adults who reported a Christian religious affiliation and who sought religiously based, group-psychotherapy treatment for difficulties in their emotional experience of God (i.e., negative god images). The treatment protocol reflected a psychotherapy-integrationist approach to treating god-image difficulties. Treatment chiefly included psychoeducational, dynamic-interpersonal, and cognitive interventions, although it also included allegorical-hibliotherapy and art/music interventions. The pre- and post-test questionnaire included the Attachment to God Inventory (R. Beck & McDonald, 2004) and a brief God adjective-checklist, along with several open-ended questions. Participants reported experiencing adaptive shifts in their god images and attachment to God. Specifically, when pre- and post-questionnaire ratings were compared, they reported experiencing God emotionally as more accepting, intimate, and supportive and as less disapproving, distant, and harsh. In addition, they reported experiencing significantly both less attachment anxiety with God and less attachment avoidance with God. Furthermore, they reported experiencing more congruence between their emotional experience of God (god images) and their theological beliefs about God (god concepts). The interventions that were deemed the most therapeutically effective were the allegorical-bibliotherapy and the cognitive-restructuring interventions. Clinical implications and limitations are discussed.

As Hathaway (2003) has highlighted, within the broad field of mental health, the past 20 years have marked a significant increase in the clinical attention that is devoted to religious/spiritual issues. For example, the American Psychological Association's (2002) Ethics Code now includes religion among the domains of diversity that mental-health professionals must address in a respectful and culturally responsive manner (Hays, 2007; Richards & Bergin, 2000). Another such development is the inclusion of the Religious or Spiritual Problem diagnostic category (V62.89) in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (American Psychiatric Association, 1994; see Turner, Lukoff, Barnhouse, & Lu, 1995). As its name implies, this category is meant to be used "when the focus of clinical attention is a religious or spiritual problem" (American Psychiatric Association, 1994, p. 685). For religiously/ spiritually oriented clients, god-image difficulties are a common Religious or Spiritual Problem that motivates them to seek psychotherapy (Allmond, 2009). In particular, such clients often experience a clinically significant discrepancy between their god concepts and their god images (Yarborough, 2009)-that is, between their head knowledge of a divine attachment figure (DAF; e.g., God, Allah, Jesus, Buddha, Krishna, etc.) and their heart knowledge of that same figure, respectively (Davis, 2010; Moriarty & Davis, in press).

In the current article, we report findings from a pilot study of an 8-week, manualized, outpatient group-psychotherapy intervention (entitled "Discovering God") that was designed to treat god-image difficulties, with a specific view toward improving client god images and attachment to God. Our treatment protocol reflected a psychotherapy-integrationist approach (Norcross & Golfried, 2005; cf. Moriarty & Davis, in press). It chiefly included psychoeducational, dynamic-interpersonal, and cognitive interventions, although it also included allegorical-bibliotherapy and art/music interventions. In the section that follows, we will briefly describe our psychodynamic-cognitive conceptualization of god images, on which both our treatment manual and our clinical interventions were based.

DEFINITIONS, DEVELOPMENT, AND DYNAMICS

Definitions

As Davis (2010) has described, god images are the affect-laden mental representations that underlie a person's embodied, emotional experiences in relationship with a DAF, such as God, Allah, Jesus, Buddha, or Krishna. They are primarily comprised of implicit relational knowledge (i.e., "gut-level procedural knowledge of how to perceive and be in relationship with a general or specific relational partner," Moriarty & Davis, in press; cf. Hall, 2004; Kihlstrom, 2008; Lyons-Ruth et al., 1998). Basically, god images "guide and integrate how a person experiences [the DAF] at an emotional, physiological, largely nonverbal, and usually implicit level (i.e., outside of conscious awareness; Davis, 2010; cf. Fogel, 2009; Noffke & Hall, 2007)" (Moriarty & Davis, in press). Hall (2007) has thus described god images as a type of attachment filter (p. 24), through which embodied, emotional experiences with a DAF are mediated.

In contrast, god concepts are the belief-laden mental representations that underlie a person's conscious, linear knowledge about a DAF. They are chiefly comprised of semantic memory (i.e., "general knowledge about the world, including words and concepts, their properties and interrelations," Smith & Kosslyn, 2007, p. 541; cf. Davis, 2010; Siegel, 2010), Essentially, they guide and integrate how a person thinks and talks about a DAF at an abstract, theological, conceptual, and usually explicit level (i.e., inside of conscious awareness; Davis, 2010). As such, god concepts may be thought of as a type of doctrinal filter, through which theological, abstract thoughts and discussions about a DAF are mediated (cf. Hall, 2007).

Development and Dynamics

God-image development and dynamics. It is beyond the scope of this article to comprehensively describe the development and dynamics of god images and god concepts (see Davis, 2010; Moriarty & Davis, in press, for such reviews). However, we will provide a brief summary here, highlighting the points that group-participants read about in our treatment manual (see Thomas, 2009, Appendix G, for a copy of this manual).

As Davis (2010) has detailed, our conceptualization of god-image development and dynamics is based on Hall's (2004) relational-spirituality theory (cf. Hail, 2007; Hall, Fujikawa, Halcrow, Hill, & Delaney, 2009). Consequently, it is undergirded by the central organizing principles of that theory, as enumerated in Hall (2004):

Central Organizing Principle #1. People are fundamentally motivated by, and develop in the context of emotionally significant relationships. (p. 68)

Central Organizing Principle #2. There are multiple codes of emotional information processing which provide a theoretical framework for understanding the way in which close relationships are processed and internalized, thereby shaping the patterns of our relationships with God, self and others. (p. 69)

Central Organizing Principle #3. Implicit relational representations are repetitions of relational experiences, sharing a common affective core, that are conceptually encoded in the mind as non-propositional meaning structures. They are the memory basis for implicit relational knowledge; that is, our "gut level" sense of how significant relationships work. (p. 71)

Central Organizing Principle #4. Implicit relational representations, formed particularly from experiences [in] early relationships with caregivers, shape the emotional appraisal of meaning and subsequent patterns of relationship. (p. 72)

Central Organizing Principle #5. Implicit relational representations and knowledge form the foundation of our knowledge of self and others because they are processed automatically, and are not under the direct control of knowledge in the form of words that [are] processed in a linear manner. (pp. 73-74)

Our treatment manual reflected a psychotherapy-integrationist approach (Norcross & Goldfried, 2005; cf. Moriarty & Davis, in press). As such, our conceptualization of god-image development and dynamics highlighted ideas from several theoretical traditions. For example, from the classical-psychoanalytic tradition (Freud, 1913/1950, 1930/1962; Jones, 1991, 2007), we stressed the pervasive and long-lasting influence of early-childhood experiences in relationship with one's caregivers. From the object relations tradition (Rizzuto, 1979; Winnicott, 1951/1975, 1971), we emphasized the processes of internalization (Davis, 2010; Moriarty, 2006; Schafer, 1968) and of separation-individuation (Mahler, Pine, & Bergman, 1975), the former via the caregiver-child relationship and the latter via the use of God as a transitional object (Moriarty, 2006; Winnicott, 1951/1975, 1971). From the cognitive tradition (A. T. Beck, Rush, Shaw, & Emery, 1979; DeRubeis, Tang, & A. T. Beck, 2001), we underscored the concepts of core beliefs (Moriarty, 2006), automatic thoughts (A. T. Beck et al., 1979), self-schemas (Markus, 1977; Markus & Kunda, 1986), and cognitive distortions (DeRubeis et al., 2001). Last, from the attachment tradition (Bowlby, 1973; Collins, Guichard, Ford, & Feeney, 2004), we underlined the interconnections among internal working models of self, God, and others, particularly the reliable similarities between one's global (i.e., generalized) internal working models of self and one's global internal working models of God (Benson & Spilka, 1973; Buri & Mueller, 1993; Yarborough, 2009; cf. Davis, 2010; Hall et al., 2009; Moriarty & Davis, in press).

In this latter regard, our conceptualization of god-image development and dynamics affirmed the implicit-relational-knowledge correspondence hypothesis (Hall, 2004, 2007; Hall et al., 2009), which posits that individuals' experiences in relationship with human attachment figures (e.g., caregivers, peers, romantic partners, and coreligionists) undergirds and parallels their experiences in embodied, emotional relationship with God. Importantly, according to this hypothesis, people's implicit relational knowledge of how to perceive and be in relationship with God is reflected in their implicit religious/spiritual functioning (i.e., "their felt religious/spiritual experience at a relational, motivational, emotional, and physiological level," Moriarty & Davis, in press) but not necessarily in their explicit religious/spiritual functioning (i.e., "their religious/spiritual behaviors and consciously articulated beliefs; e.g., religious/spiritual commitment, church attendance, and theological beliefs," Moriarty & Davis, in press; see Davis, 2010; Hall et al., 2009, for reviews).

There is preliminary research support for the implicit-relational-knowledge hypothesis (Davis, 2010; Hall et al., 2009). For example, Hall et al. (2009) found that adult participants from the four main attachment groups (secure, anxious, avoidant, and fearful) differed significantly on three of four implicit religious/spiritual functioning indicators (interpersonal unforgiveness, spiritual community, and attachment anxiety with God) but did not exhibit significant differences on the explicit religious/spiritual functioning indicator (explicit religious/spiritual commitment).

God-concept development and dynamics. In contrast to their god images, people's god concepts are highly related to their explicit religious/spiritual history and functioning. Hoffman (2005) has described god concepts as mainly deriving from informal and formal learning, via such avenues as religious/spiritual texts and the teaching and modeling of parents and religious/spiritual leaders (Davis, 2010; Grimes, 2007).

In the case of religious/spiritual persons who report having a personal relationship with a DAF, it is likely that their god concepts are relatively adaptive and "accurate," from the standpoint of their primary religious/spiritual texts (e.g., the Bible, Book of Mormon, Qur'an; Davis & Moriarty, 2008). However, religious/spiritual individuals often experience disparities between the DAF they believe in explicitly (god concepts) and the DAF they experience implicitly (god images; see Davis, 2010; Lawrence, 1997; Moriarty, 2006; Moriarty & Davis, in press). The degree and qualitative nature of such disparities will vary from person to person. Significant disparities may reflect the operation of what Bucci (1997) has termed desymbolization or dissociation, whereby "the connections between the subsymbolic and the symbolic components of the schemas are cut" (Bucci, 1997, p. 202; cf. Davis, 2010; Davis & Moriarty, 2008) or what interpersonal neurobiologists (e.g., Badenoch, 2008; Siegel, 2010) have referred to as a lack of integration, where integration is defined as the "linkage of differentiated parts of a system [e.g., the mind/bran-1]" (Siegel, 2010, p. 262; see Davis, 2010, for a review).

RESEARCH ON PROMOTING GOD-IMAGE CHANGE THROUGH PSYCHOTHERAPY

Research on promoting god-image change through psychotherapy is admittedly sparse. At the time of writing this article (February 2011), there were only two published, peer-reviewed studies in this area: Tisdale et al. (1997) and Cheston, Piedmont, Eanes, and Lavin (2003).

Tisdale et al. (1997)

First, Tisdale et al. (1997) examined god-image change through religiously based, object-relations-oriented, multimodal inpatient-psychiatric treatment. All participants were self-identified evangelical Christians and most of them were Caucasian and of middle or upper-middle socioeconomic status. The mean age was 37 (range: 17-65 years old). Most participants had a primary diagnosis of Major Depressive Disorder and had never before been psychiatrically hospitalized. The average length of hospitalization was 20.2 days (range: 10-43 days).

The following self-report measures were administered at admission (N = 99), at discharge (N= 99), at 6 months following discharge (n = 67), and at 12 months following discharge (n = 30): (a) the Bell Object Relations Reality Testing Inventory (Bell, 1991; measuring object relations maturity and reality testing); (b) the Personal Self subscale of the Tennessee Self-Concept Scale (Fitts, 1965; measuring overall self-worth); (c) the Presence, Challenge, and Acceptance subscales of the God Image Scales (Lawrence, 1997; measuring God's felt presence, desire for one's growth, and valuation of one's boy-ability, respectively); and (d) the Religious Experience Questionnaire (Edwards, 1976; measuring the overall experience of God emotionally as loving and close). Psychiatric inpatient treatment included the following interventions: (a) pharmacotherapy (as needed), (b) 30 minutes of individual psychotherapy (5 days per week), (c) 90 minutes of group psychotherapy (7 days per week), (d) 60 minutes of religiously based psychoeducation (7 days per week), and (e) milieu treatment (e.g., occupational therapy, community meetings, and vocational counseling; as needed; Tisdale et al., 1997).

Overall, participants reported experiencing adaptive changes in their god images, when their admission and discharge scores were compared. Specifically, at the end of their psychiatric-inpatient treatment, they reported experiencing God emotionally as more close, loving, accepting, and present, compared with when they entered treatment. These therapeutic gains were maintained over the course of the 12-month follow-up, although without further improvements. It is important to note that adaptive changes in participants' god images were consistently associated with adaptive changes in their self-images. In fact, these adaptive shifts in self-images were dramatic in comparison to the adaptive shifts in god images, suggesting that god-image change is associated with (and perhaps evenmediated by) improvements in self-images. Improvements in self-worth were also retained across the 12-month follow-up period (Tisdale et al., 1997; cf. Davis, 2010; Moriarty & Davis, in press).

Cheston et al. (2003)

In a similar study, Cheston et al. (2003) examined god-image change through general (i.e., not necessarily religiously based) outpatient individual-psychotherapy. Participants included a nonrandomized convenience sample of 98 adults-30 in the treatment group (23 women, 7 men; mean age: 39.3 years) and 68 in the control group (53 women, 15 men; mean age: 50.1 years). All participants completed two self-report measures--the God Adjective Check List (Gough & Heilbrum, 1983; measuring god-image characteristics) and the Brief Symptom Inventory (Derogatis, 1993; measuring psychological symptoms). The 30 individuals in the treatment group completed these measures within 4 weeks of beginning psychotherapy (time 1) and then either at termination or at the end of 6 months (time 2), whichever came later. The 68 individuals in the control group completed these measures at point of first contact (time 1) and then from 2 to 6 months later (mean intertest interval: 4 months). For the individuals in the treatment group, the mean intertest interval was 6.7 months (range: 6-19 months), and the mean number of sessions was 20 (range: 2-52 sessions). Of note, at time 1 and time 2, each psychotherapy-client's therapist completed the Derogatis Psychiatric Rating Scale (Derogatis, 1978; a clinician-rated measure of psychological symptoms) on the respective client. Also, at time 2, the therapist rated the client's overall emotional growth (single-item measure) and overall spiritual growth (single-item measure).

When self-ratings at time 1 and time 2 were compared, psychotherapy participants reported experiencing significantly decreased psychological symptoms over time, whereas control participants tended to reliably remain asymptomatic. Similarly, psychotherapy participants reported experiencing adaptive changes in their god images over time, whereas control participants tended to reliably experience God in an emotionally healthy manner. More specifically, psychotherapy participants reported experiencing God emotionally as lower in trait neuroticism and as higher in trait agreeableness; however, this treatment effect was only evidenced among those clients who showed high emotional growth over time, as per clinician-rating. Moreover, the clients who evidenced high spiritual growth over time tended to show a concomitant shift in experiencing God emotionally as more loving, caring, and compassionate (Cheston et al., 2003). As Moriarty and Davis (in press) have concluded

Cheston et al.'s study suggests the possibility that the common factors of psychotherapy (e.g., empathy, positive regard) may facilitate god-image change indirectly, via other forms of emotional change, such as improvements in self-image and adaptive shifts in implicit relational knowledge.

Furthermore, as Cheston et al. (2003) indicated: "The psychological and spiritual selves of clients may be integrally connected; thus, when something shifts for one part of the self, it shifts for another part of the self as well" (Cheston et al., 2003, p. 106).

Current State of the Research Evidence

Taken together, Tisdale et al. (1997) and Cheston et al. (2003) have offered research evidence that adaptive god-image change can be effected through (a) religiously based, object-relations-oriented, multi-modal inpatient-psychiatric treatment (Tisdale et al., 1997) and (b) general outpatient individual-psychotherapy (Cheston et al., 2003). However, each of these studies suffered from notable methodological limitations. For example, for ethical reasons (e.g., psychiatric inpatients ethically cannot be put onto a waiting list), Tisdale et al.'s study did not have a control group, thereby limiting internal validity. In addition, Tisdale et al. did not evaluate the relative effects of the different inpatient-treatment components, thereby limiting treatment specificity (i.e., conclusions regarding the active ingredients of patient change; Chambless & Hollon, 1998; Chambless & 011endick, 2001).

Cheston et al.'s (2003) study was more methodologically rigorous. Even so, there were noteworthy limitations in that study also. For instance, the treatment group was small (N = 30), thus limiting power, and females were over-represented (n = 23), thus limiting external validity. Moreover, Cheston et al. did not randomly assign treatment and control participants, limiting the study's internal validity. Furthermore, they did not evaluate the degree to which religious/spiritual components were explicitly addressed in psychotherapy, limiting an understanding of the treatment specificity (Chambless & Hollon, 1998; Chambless & Ollendick, 2001). In sum, the research evidence on promoting god-image change through psychotherapy participation is still preliminary.

The Current Study

In our pilot study, we sought to build on this research by (a) studying a manualized treatment intervention and (b) studying the specific impact of religiously based, psychotherapy integrationist, outpatient group-psychotherapy. Building on the above-mentioned research findings, we predicted the following, with regards to group-participants' answers on the pre- and post-questionnaires:

a. Hypothesis 1. We predicted that group participants would report experiencing less attachment anxiety with God.

b. Hypothesis 2. We predicted that group participants would report experiencing less attachment avoidance with God.

c. Hypothesis 3. We predicted that group participants would report experiencing God emotionally as more accepting, intimate, and supportive.

d. Hypothesis 4. We predicted that group participants would report experiencing God emotionally as less disapproving, distant, and harsh.

e. Hypothesis 5. We predicted that group participants would report experiencing more congruence between their emotional experience of God (god images) and their theological beliefs about God (god concepts).

METHOD

Participants

Participants were adults who sought group-psychotherapy treatment for difficulties in their emotional experience of God (i.e., negative god images). As such, each group member had a primary diagnosis of Religious or Spiritual Problem (V62.89; American Psychiatric Association, 1994). Several members had a secondary diagnosis of Major Depressive Disorder or Anxiety Disorder Not Otherwise Specified. Notably, 10 group members were concurrently receiving religiously based, outpatient individual-psychotherapy and/or pharmacotherapy.

Screening and attrition. Thirty-seven individuals participated in the study's screening session. At that point, four participants decided not to participate in the study, and one person was screened out because other clinical difficulties were more prominent and necessitated more in-depth treatment than our manualized group-psychotherapy intervention was able to provide. Thirty-two participants began the group-psychotherapy process, but six individuals dropped out, for various reasons (e.g., one individual moved out of the area, two decided to solely participate in individual-psychotherapy, and three did not provide a reason).

Pilot-study sample. In the end, 26 adults (11 men, 15 women, Mage = 29.6, SDage = 6.56, age range: 1946 years old) completed the 8-week group-psychotherapy intervention. Most were Caucasian graduate students (from various disciplines), of middle to upper-middle socioeconomic status. Twenty-five participants reported a Protestant-Christian affiliation; one, a Catholic-Christian affiliation. A total of seven psychotherapy-groups were conducted, each using the same 8-week manualized treatment protocol. The mean number of group participants was 3.7, and all groups included both male and female participants.

Group Psychotherapists

Each group was facilitated by two doctoral-level students in clinical psychology--one male and one female. In total, there were seven group psychotherapists who facilitated these groups. Each psychotherapist participated in a 4-hour training that was aimed at preparing them to effectively co-facilitate their respective group, in faithful adherence to the manualized treatment protocol. Partly to ensure adequate client care and partly to ensure protocol adherence, this article's second author (GLM) met with the psychotherapists weekly for group supervision.

Procedures

Recruitment. This study was conducted at a mid-Atlantic, religious university. Participants were primarily recruited from the student body of that institution, via on-campus publicity efforts (e.g., mails, flyers, word-of-mouth). A few other participants were recruited from the surrounding community, via local churches and a local community mental health center. The recruitment materials emphasized how the group was dedicated to helping people develop increased congruence between their head and heart knowledge of God. The flyers were labeled "Discovering God: A Group Therapy Experience" and featured a large wardrobe with a young girl peeking inside, thereby alluding to C. S. Lewis's (19501956/2001) classic book The Lion, the Witch, and the Wardrobe.

Manualized treatment protocol. Prior to the screening session, all prospective participants read and signed an informed consent form and then completed a demographic form. Of the pilot-study sample (N = 26), all participants completed the pre-test questionnaire following session 1 and the post-test questionnaire following session 8. They also received a copy of the study's debriefing form, following session 8. The entire manualized treatment protocol consisted of eight, 90-minute group-psychotherapy sessions. Sec Table 1 for an overview of the manualized treatment protocol (see Thomas, 2009, Appendix C, for a copy).

MATERIALS

The pre- and post-test questionnaire included the Attachment to God Inventory (R. Beck & McDonald, 2004) and a brief God adjective-checklist, along with several open-ended questions. The Attachment to God Inventory (AGI) is a 28-item self-report measure of adult attachment tendencies in emotional relationship with God. It is a self-report, survey-based measure of implicit relational spirituality (Hall et al., 2009) and thereby of god images. The AGI consists of two subscales--the Anxiety subscale (measuring anxiety about abandonment; e.g., "I worry a lot about my relationship with God") and the Avoidance subscale (measuring avoidance of intimacy; e.g., "I am uncomfortable being emotional in my communication with God"). Each subscale contains 14 items, some of which are reverse-scored and all of which involve rating along a seven-point Likert scale (ranging from 1 = disagree strongly to 4 = neutral/mixed to 7 = agree strongly; R. Beck & McDonald, 2004).

Our brief God adjective-checklist was developed for this study. It consisted of three positively valenced trait adjectives--accepting, intimate, and supportive--and three negatively valenced trait adjectives--disapproving, distant, and harsh. Respondents rated the degree to which the trait adjective tended to describe how they experienced

TABLE 1

An Overview of the Manualized Treatment Protocol

Session Context Intervention description

        In-session      Welcome and introductions
1                       Group overview, ground rules, and basic
                        rationale
                        Completion of the Draw-A-God figure-drawing
                        (Moriarty, 2006)
                        Psychoeducation on god images and god concepts
                        Discussion of god-image/god-concept
                        discrepancies
        Post-session    Completion of the pre-test questionnaire
        Homework        Parent/God-Image Grids exercise examining the
                        relative impact of early caregiver-child
                        relationships on god images (Moriarty, 2006)

2       In-session      Review of homework
                        Psychoeducation on and discussion of the
                        connections between early-childhood experiences
                        (e.g., wounds) and subsequent god-image
                        difficulties
                        Dynamic-interpersonal exercise in which members
                        play the role of "the Real God," speaking to
                        another member's wounds
                        Psychoeducation on god-image development
                       (psychodynamic view)
        Homework        Select a meaningful song/hymn and read its
                        lyrics twice daily

3       In-session      Review of homework
                        Psychoeducation on an orthodox Christian
                        theology of god images, followed by an
                        introduction to a cognitive-theory view of god
                        images
                        Discussion and film clip of the
                        thoughts-feelings connection
                        Write a spiritual-journal letter to oneself from
                        the Real God
        Homework        Continue to read the meaningful song/hymn twice
                        daily

4     In-session        Further psychoeducation on a cognitive-theory
                        view of god images
                        Psychoeducation on the God Image Automatic
                        Thought Record (GIATR;
                        Moriarty, 2006), followed by verbal practice
                        completing one
        Homework        Complete the GIATR in writing, at least 3 times
                        during the week
                        Attend a 30-minute individual-psychotherapy
                        session with a group cofacilitator, to discuss
                        treatment progress and to complete a GIATR
                        Begin to sing the meaningful song/hymn twice
                        daily

5       In-session      Psychoeducation on cognitive distortions,
                        interspersed with applied discussion
        Homework        Complete the GIATR in writing, at least 3 more
                        times during the week
                        Start to read the C. S. Lewis (1950-1956/2001)
                        book The Horse and His Boy
                        Continue to sing the meaningful song/hymn twice
                        daily, and add another song/hymn

6       In-session      Psychoeducation on schemas and god images,
                        interspersed with applied discussion
        Homework        Continue to complete GIATRs and to read The
                        Horse and His Boy
                        Continue singing the songs/hymns twice daily but
                        may change them at any time

7      In-session       Psychoeducation on
                        allegorical-bibliotherapy and its use in
                        changing god images
                        Discussion of reactions to The Horse and His
                        Boy, focusing on experiences of Asian
                        Exercise of watching and discussing reactions to
                        a film clip depicting Asian
        Homework        Continue to complete GIATRs
                        Continue singing the songs/hymns twice daily but
                        may change them at any time
                        Write down a word of encouragement for each
                        group member, to share next session

8       In-session      Group overview, reflections, and celebration
                        Dynamic-interpersonal exercise in which members
                        encourage and thank one another for their
                        respective growth-promoting contributions to the
                        group
        Post-session    Completion of the post-test questionnaire

God emotionally, using a five-point Likert scale that ranged from 1 (very accurate) to 3 (neutral) to 5 (very inaccurate).

On both the pre- and post-test questionnaires, participants were asked to rate how similar their emotional experience of God (god images) was to their theological beliefs about God (god concepts), using a ten-point Likert scale in which lower scores indicated lower congruence and higher scores indicated higher congruence. Last, on the post-test questionnaire only, participants were asked three exploratory, open-ended questions. Specifically, they were asked to identify (a) the psychological intervention that most influenced their emotional experience of God, (b) the treatment-manual component that most influenced their emotional experience of God, and (c) the primary mechanism by which interactions with other group members influenced their emotional experience with God.

RESULTS

Hypotheses 1 and 2

We predicted that group participants would report experiencing less attachment anxiety with God (Hypothesis 1) and less attachment avoidance with God (Hypothesis 2). Paired-samples t tests yielded support for each of these hypotheses (see Table 2). Only 20 pilot-study participants completed the AGI, because it was not administered to the first psychotherapy group (n = 4), and two other group members did not complete all the AGI items, for unknown reasons.

Hypotheses 3 and 4

We predicted that group participants would report experiencing God emotionally as more accepting, intimate, and supportive (Hypothesis 3) and as less disapproving, distant, and harsh (Hypothesis 4). Paired samples t tests yielded support for each of these hypotheses (see Table 3). All 26 pilot-study participants completed the brief God adjective-checklist.

TABLE 2

Contrast of Pre- and Post-Test Scores on the Attachment to
God Inventory (N = 20)

                                 Pre-test      Post-test
Variable                          M (SD)        M (SD)     t( 19)
Attachment anxiety with God    69.90 (17.5)  56.50 (20.5)   4.25
Attachment avoidance with God  50.60 (178)   43.70 (14.5)   3.57

Variable                         P
Attachment anxiety with God    .001
Attachment avoidance with God  .002

Note. For each subscale of the Attachment to God Inventory,
higherscores indicate higher levels of the assessed attachment
tendency, and total subscale scores can range from 7 to 98.

TABLE 3

Contrast of Pre- and Post-Test Scores on the Brief God
Adjective-Checklist (N = 26)

                                       Pre-test   Post-test

Variable                                M (SD)      M (SD)    t(25)

Positively valenced trait adjectives

Accepting                             3.08 (1.3)  1.80 (0.7)  5.94
Intimate                              3.23 (1.4)   185 (10)   5.72
Supportive                            2.73 (13)   L85 (0.9)   3.00

Negatively vaIenced trait adjectives

Disapproving                          2.15 (12)   3.62 (0.9)  -6.54
Distant                               165 (0.9)   3.58 (13)   -6.68
Harsh                                 3.00 (14)   4.04 (0.9)  -4.24

Variable                                p

Positively valenced trait adjectives

Accepting                             .001
Intimate                              .001
Supportive                            .006

Negatively vaIenced trait adjectives
Disapproving                          .001
Distant                               .001
Harsh                                 .001

Note. For each trait adjective, lower scores indicate
higher levels of the degree to which the trait adjective
self-reportedly describes one's emotional experience of
God, with scores ranging from I (very accurate) to 3
(neutral) to 5 (very inaccurate).

Hypothesis 5

We predicted that group participants would report experiencing more congruence between their emotional experience of God (god images) and their theological beliefs about God (god concepts) at the end of treatment. As stated previously, on the pre- and post-test questionnaires, participants were asked to rate how similar their emotional experience of God was to their theological beliefs about God, using a ten-point Likert scale in which lower scores indicated lower congruence and higher scores indicated higher congruence. (All 26 pilot-study participants completed this item.) To quantify this god-image/god-concept discrepancy, we categorized respondents based on their item-rating: (a) Severe Discrepancy (ratings of 1 to 3), (b) Moderate Discrepancy (4 to .5), (c) Mild Discrepancy (6 to 7), and (d) Minimal Discrepancy (8 to 10). On the pre-test questionnaire, the frequency breakdown was as follows: (a) Severe Discrepancy (n = 10), (b) Moderate Discrepancy (n = 9), (c) Mild Discrepancy (n = 5), and (d) Minimal Discrepancy (n = 2). In contrast, on the post-test questionnaire, the frequency breakdown was as follows: (a) Severe Discrepancy (n = 1), (b) Moderate Discrepancy (n = 4), (c) Mild Discrepancy (n = 12), and (d) Minimal Discrepancy (n = 9). To statistically examine this quasi-interval data, we conducted a paired-samples t test, which revealed support for Hypothesis 5 as well, t(25) = -5.84, p [less than] .001.

TABLE 4

Most Commonly Cited Answers to Open-Ended Questions on
the Post-Test Questionnaire (n = 23)

Commonly cited answer                               n

Most influential intervention

The Horse and His Boy (allegorical-bibliotherapy)   9

God Image Automatic Thought Record (cognitive       7
restructuring)

Psychoeducation on connections between              4
early-childhood experiences and subsequent
god-image difficulties

Most influential treatment-manual component

God Image Automatic Thought Record (cognitive       9
restructuring)

Parent/God-Image Grids exercise examining the       9
relative impact of early caregiver-child
relationships on god images (Moriarty, 2006)

Psychoeducation on connections between              4
early-childhood experiences and subsequent
god-image difficulties

Primary mechanism of group-member influence
Open sharing and insightful comments from other     13
group members (interpersonal input and output)

Feeling as if they were not alone and as if they    10
were experiencing similar difficulties to other
group members (universality)

Safe environment allowed for authentic interaction  6
among group members (cohesiveness and catharsis)

Commonly cited answer                               [percentage] of
                                                           n
Most influential intervention

The Horse and His Boy (allegorical-bibliotherapy)   39[percentage]

God Image Automatic Thought Record (cognitive       30[percentage]
restructuring)

Psychoeducation on connections between              17[percentage]
early-childhood experiences and subsequent
god-image difficulties

Most influential treatment-manual component

God Image Automatic Thought Record (cognitive       39[percentage]
restructuring)

Parent/God-Image Grids exercise examining the       39[percentage]
relative impact of early caregiver-child
relationships on god images (Moriarty, 2006)

Psychoeducation on connections between              17[percentage]
early-childhood experiences and subsequent
god-image difficulties

Primary mechanism of group-member influence
Open sharing and insightful comments from other     57[percentage]
group members (interpersonal input and output)

Feeling as if they were not alone and as if they    43[percentage]
were experiencing similar difficulties to other
group members (universality)

Safe environment allowed for authentic interaction  26[percentage]
among group members (cohesiveness and catharsis)

Exploratory Analyses

As stated above, on the post-test questionnaire, participants were asked to identify (a) the psychological intervention that most influenced their emotional experience of God, (b) the treatment-manual component that most influenced their emotional experience of God, and (c) the primary mechanism by which interactions with other group members influenced their emotional experience with God. See Table 4 for the most commonly cited answers to each of these three open-ended questions. Only 23 participants answered this portion of the questionnaire.

DISCUSSION

Summary of Findings

In sum, on average, participants in our 8-week, manualized, outpatient group-psychotherapy intervention reported experiencing adaptive shifts in their god images and attachment to God. Specifically, when pre- and post-questionnaire ratings were compared, they reported experiencing God emotionally as more accepting, intimate, and supportive and as less disapproving, distant, and harsh. In addition, they reported experiencing significantly both less attachment anxiety with God and less attachment avoidance with God. Furthermore, they reported experiencing more congruence between their emotional experience of God (god images) and their theological beliefs about God (god concepts). Last, the interventions that were deemed the most therapeutically effective were the allegorical-bibliotherapy and the cognitive-restructuring interventions.

Clinical Implications

Our pilot study has several implications for clinicians who are addressing god-image difficulties in clinical practice. Perhaps most substantively, our findings support Rizzuto's (1974) claim that god images are indeed changeable. Our findings provide further support that psychotherapeutic treatment can lead to adaptive changes in god images, as Tisdale et al. (1997) and Chcston et al. (2003) have previously shown.

Our results also provide preliminary support for the possibility that group psychotherapy is an effective treatment format for treating negative god images. This finding is consistent with the findings of O'Hare (2003), whose small-scale dissertation study (N = 6) also revealed evidence that group psychotherapy can lead to adaptive god-image change.

As stated above, our participants were asked to identify the primary mechanism by which interactions with other group members influenced their emotional experience with God. Here, the most commonly cited answers were (a) open sharing and insightful comments from other group members (interpersonal input and output), (h) feeling as if they were not alone and as if they were experiencing similar difficulties to other group members (universality), and (c) that the safe environment allowed for authentic interaction among group members (cohesiveness and catharsis). Speaking of god-image treatment in a group-psychotherapy format, Moriarty and Davis (in press) have highlighted the potential for the relationships among group members to provide yet another change mechanism, in addition to actual psychological interventions. Our findings support this possibility. Indeed, group members consistently reported that their interactions with other group members had a substantive positive impact on their god images, particularly the open sharing and insightful comments from other group members (interpersonal input and output). In addition, many participants initially felt as if they were alone in their god-image struggle, but through meeting other people who had similar problems (universality), they were able to connect with each other and to grow toward health--individually and collectively. In short, our results are consistent with the reliable research finding that interpersonal input, interpersonal output, and universality are among the therapeutic factors that outpatient group-psychotherapy participants frequently cite as powerful change mechanisms (see Yalom & Leszcz, 2005, p. 88). Our participants also felt as if the safe environment of the group allowed for authentic interaction among group members, and this cited change mechanism seems to relate to the therapeutic factors of cohesiveness (related to the experience of safety) and catharsis (related to the experience of authentic interaction; Yalom & Leszcz, 2005, p. 88).

Our research provides preliminary support for the use of a manualized group-therapy protocol in the treatment of god-image difficulties, as well as for the use of a psychotherapy-integrationist approach in such treatment (Norcross & Goldfried, 2005; cf. Moriarty & Davis, in press). When we asked participants to identify the treatment-manual components that were the most influential in promoting adaptive change in their god images, the most frequently cited answers were (a) the GIATR (cognitive restructuring), (b) the Parent/God-Image Grids exercise (examining the relative impact of early caregiver-child relationships on god images [Moriarty, 20061), and (c) psychoeducation on connections between early-childhood experiences and subsequent god-image difficulties. All these components relate to the change mechanism of increases in self-understanding, which is another mechanism that outpatient group-psychotherapy participants often cite as effective (Yalom & Leszcz, 2005, p. 88).

Next, our results provide preliminary evidence that allegorical-bibliotherapy and cognitive-restructuring interventions are particularly effective mechanisms for promoting adaptive shifts in god images and attachment to God. With regard to allegorical-bibliotherapy interventions, Moriarty and Davis (in press) have discussed the use of the Chronicles of Narnia series (Lewis, 1950-1956/2011):

Christian clients readily identify with the characters who interact with Asian (i.e., God). Through identification with these characters, clients learn to make sense of difficult personal situations and to experience God emotionally as more affirming and experience-near, particularly during trying times.

Indeed, in our study, thirty-nine percent of the participants stated that reading C. S. Lewis's The Horse and His Boy was influential in improving their god images. This book specifically addresses the role of God in the pain and suffering of different characters in the book. Although we did not ask our participants what specific elements of the allegorical-bibliotherapy were impactful for them, we did have a few notable observations. First, participants stated they were able to empathize with many characters in the novel. Many characters inappropriately perceived Asian (i.e., God) to be distant and harsh when in fact he was intimate and intentional in how and when he interacted with each character. Given that many participants initially experienced God emotionally as distant, it was profoundly healing for them to read a novel in which the God-figure (Asian) is convincingly and poignantly portrayed as ever-present and experience-near. Thus, the impactful theme that emerged through reflecting on the novel was that although God may seem distant or harsh at times, God's actions are perhaps more appropriately viewed as intimate, intentional, loving, and caring, even when they do not feel like it in the moment. Remarkably, by and large, group participants were able to internalize this message and to generalize it to their own emotional experience of God.

Second, in their experience of the allegorical-bibliotherapy intervention, participants reported that they experienced relief from reading and reflecting on the words Asian spoke in the novel. In The Horse and His Boy (1950-1956/2011), when Asian enters into the allegorical-narrative, he often speaks words that encourage, affirm, and empower the character(s) with whom he is interacting. Many participants reported that these words from Aslan were encouraging, affirming, and empowering for them as well, particularly as it related to promoting their ability to experience God emotionally as more accepting, intimate, and supportive.

With regard to the use of cognitive-restructuring interventions (e.g., GIATRs), it is noteworthy to point out that our use of GIATRs was quite incorporative of emotions (see Moriarty & Davis, in press, for a description of this intervention and for a copy of the GIATR). Here, we were mindful of the dangers Moriarty and Davis (in press) have addressed elsewhere:

While treating god-image concerns with cognitive-behavioral interventions, it is easy to focus solely on thoughts and behaviors, thereby fostering surface-Ievel shifts in client god concepts instead of promoting deeper-level changes in client god images. Fortunately, cognitive-behavioral techniques can be used in ways that affirm and involve both cognition and emotion. (cf. Cozolino, 2010)

Limitations

Lack of a control group. As stated above, both Tisdale et al.'s (1997) and Cheston et al.'s (2003) studies had notable limitations, and our pilot study was no exception. Perhaps most notably, as with Tisdale et al.'s study, our pilot study did not have a control group (and thus there was no random assignment), given the exploratory nature of our research. Consequently, we are unable to offer definitive conclusions regarding what caused the changes in participants' god images and attachment to God.

Limits to treatment specificity. This threat to our study's internal validity is also related to the fact that, during at least a portion of our study, ten of our group-therapy participants were concurrently in individual psychotherapy, most often for the treatment of depression and/or anxiety. Therefore, it is difficult to specify the degree to which our study's findings were due to our group-psychotherapy intervention, compared with the relative influence of other factors (e.g., individual psychotherapy, extratherapy factors).

Low sample size. Another limitation of our study was its low sample size (N = 26). Having such a low number of participants limited our study's power. Even so, the fact that all our hypotheses were statistically supported with such low power provides promising evidence that true differences in the examined variables exist.

Limits to external validity. One more limitation of our study was the demographic makeup of our sample. Our population of interest was adults who report having difficulties in their emotional experience of God (i.e., negative god images). Even though our sample was generally representative in terms of gender (11 men, 15 women), it was over-representative of young, highly educated, Caucasian, Protestant-Christian adults, of middle to upper-middle socioeconomic status. Thus, study's findings are most appropriately generalized to young adults who are demographically similar to our sample.

Use of self-report, survey-based measures. Another limitation of our study was the sole use of self-report, survey-based measures. As Gibson (2007) and Moriarty and Davis (in press) have explained, such measures are the most popular way to clinically assess god images. However, these measures may be quite limited in their ability to validly assess respondents' heart knowledge of God (god images), particularly given the embodied, emotional, implicit, nonverbal nature of god-image functioning (see Davis, 2010; Moriarty & Davis, in press). In assessing god images (which largely involve right-brain mediated processes) via self-report, survey-based measures (which tend to tap into largely left-brain mediated processes; Moriarty & Davis, in press; cf. Gibson, 2007), there is often a danger that respondents will deduce the "right" (i.e., researcher-expected) answer and thus respond in a biased manner. Gibson (2007) has raised such concerns and has offered some suggestions for using self-report, survey-based measures in the most optimal manner. Following Gibson's suggestions, we framed questions in ways that explicitly asked respondents to discriminate between their head and heart knowledge of God.

In short, our study had many of the same limitations as Tisdale et al.'s (1997); both studies may be classified as Type 3 studies, according to the seminal classification system espoused in A Guide to Treatments That Work (3rd ed.; Nathan & Gorman, 2007). Nathan and Gorman (2007) have described:

[Type 3 studies] are clearly methodologically limited, Generally, Type 3 studies are open treatment studies aiming at obtaining pilot data. They are highly subject to observer bias and can usually do little more than indicate if a treatment is worth pursuing in a more rigorous design ... . Such studies can, of course, provide a great deal of naturalistic information but are prone to all of the problems of uncontrolled data collection and retrospective recall error. (pp. vii-viii)

Notably, because of its higher degree of methodological rigor, Cheston et al.'s (2003) study may be classified as a Type 2 study, which Nathan and Gorman (2007) have described in the following manner:

[Type 2 studies] arc clinical trials in which an intervention is made, but some aspects of the Type 1 study requirement are missing. For example,-- a trial in which two treatments are compared but the assignment is not randomized ... . Such studies clearly do not merit the same consideration as Type 1 studies but often make important contributions and generally should not be ignored. (p. vii)

Future Research on God Images

It is important to note that, as of yet, no specified psychological-interventions have enough research evidence to be deemed either "well-established" or "probably efficacious" in treating negative god images (Chambless & Hollon, 1998; Chambless & Ollendick, 2001). For the god-image research literature to continue to grow and mature,

Type 1 studies are especially needed. Here, Nathan and Gorman (2007) have explained: [Type 1 studies] are the most rigorous and involve a randomized, prospective clinical trial. Such studies also must involve comparison groups with random assignment, blinded assessments, clear presentation of exclusion and inclusion criteria, state-of-the-art diagnostic methods, adequate sample size to offer statistical power, and clearly described statistical methods. (p. vii)

Future psychotherapeutic-outcome research on god images should also be conducted with samples that are more representative of age, race/ethnicity, religious/spiritual affiliation, and socioeconomic status than was our pilot-study sample. Furthermore, future research should utilize a multimodal assessment approach, ideally including some combination of clinician-rated measures; implicit measures (e.g., a reaction-time test; Yarborough, 2009); projective assessments; and self-report, survey-based measures (see Gibson, 2007; Moriarty & Davis, in press, for reviews). Moreover, future research should explore the specific mechanisms of therapeutically mediated change in god images, in both individual-therapy and group-therapy formats. Last, future research should further examine the use of treatment manuals, perhaps even exploring options of either using another therapeutic modality (e.g., narrative-experiential; Moriarty & Davis, in press) or meeting in a different counseling context (e.g., a church-based setting).

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AUTHORS

THOMAS, MICHAEL. J. Address: 1300 Eagle Road, McInnis 222 St. Davids, PA 19087. Title: Visiting Assistant Professor, Eastern University. Michael also serves as a psychologist within the Brandywine Hospital Eating Disorder Program in Coatesville, Pennsylvania. Degree: Psy.D. Areas of Specialization: Clinical and research interests include eating disorders, god images, religious and spiritual issues, and positive psychology.

MORIARTY, GLENDON, L. Address: 1000 Regent University Drive, Virginia Beach, VA 23456. Email Address: glenmor@regent.edu. Phone: 757.352.4341. Title: Associate Professor, Department of Psychology, Regent University. Degree: Psy.D. Areas of Specialization: Psychodynamic psychotherapy, emotional experience of God/God images, integration of psychology and technology.

DAVIS, EDWARD. B. Address: 13800 Biola Avenue, Rose Hall 158 La Mirada, CA 90639. Email: edward.davis@biola.edu. Title: Assistant Professor, Rosemead School of Psychology (Biola University). Degree: Psy.D. Areas of Specialization: His academic, clinical, and research interests include personality psychology, psychological assessment, interpersonal neurobiology, psychology of religion/spirituality, god images, attachment, narrative identity, mindful awareness practices, and supervision/mentoring.

ANDERSON, ELIZABETH, L. Address: LSU Student Health Center Mental Health Services, Room 252 Baton Rouge, LA 70803. Email Address: elizan2@regent.edu Title: Doctoral Psychology Intern, Southern Louisiana Internship Consortium (SLIC). Psy.D. Doctoral Candidate in Clinical Psychology, Regent University. Degree. M.A. Areas of specialization: integration of psychology and spirituality; emotional experience of God/God images; psychodynamic psychotherapy; positive psychology; and interpersonal, Yalom style, dynamic group psychotherapy.

Portions of this article are reprinted from the primary author's dissertation (1-The Effect of a Manualized Group Treatment Protocol on God Image and Attachment to God,' Thomas, 2009) and from one secondary author's dissertation "Authenticity. [nailthenticity, Attachment, and God-Image Tendencies Among Adult Evangelical Protestant Christians," Davis, 2010). The authors wish to express thanks to Abrielle Conway, Seth Rainwater, Sherley Saget-Menager, and Stephanie Nowacki-Butzen, for their group cofacilitation, and to Nicholas J. S. Gibson, Mark Blagen, Stephanie Nowacki-Butzen, for their instrumentation consultation. Correspondence concerning this article should be addressed to Michael j. Thomas, Psychology Department, Eastern University, 1300 Eagle Road, McInnis Learning Center 222, St. Davids, PA 19087. E-mail: mthomall@eastern.edu.

Michael J. Thomas, Glendon L. Moriarty, Edward B. Davis, and Elizabeth L. Anderson

Doctoral Program in Clinical Psychology

Regent University