Spiritually and Religiously Oriented Health...

Spiritually andReligiously OrientedHealth Interventions

ALEX H. S . HARRIS & CARL E. THORESENStanford University

MICHAEL E. McCULLOUGH & DAVID B.LARSONNational Institute for Healthcare Research

alex harris is a PhD Candidate in CounselingPsychology at Stanford University. His researchinterests include the measurement of meaning in life,the role of forgiveness in health and disease.

carl e . thoresen is a Professor of Education,Psychology and Psychiatry/Behavioral Sciences atStanford University. Interests include psychosocialfactors in cardiovascular disease, forgiveness and thescience of spirituality.

michael e .mc cullough is Director of Researchat the National Institute for Healthcare Research inRockville, Maryland, USA. Research interests includeforgiveness and religious factors in health.

david b . larson is President, National Institute forHealthcare Research, Rockville, Maryland, USA.Interests include religious and spiritual variables inhealth.

acknowledgement. This article elaborates work reported inScientific Research on Spirituality and Health: A Consensus Report(Larson, Swyers, & McCullough, 1998).

competing interests: None declared.

address. Correspondence should be directed to:alex h . s . harris, School of Education, Counseling Psychology,Stanford University, Stanford, CA. [email: [email protected] [email protected]]

Abstract

Controlled intervention studiesoffer considerable promise tobetter understand relationshipsand possible mechanismsbetween spiritual and religiousfactors and health. Studiesexamining spiritually augmentedcognitive–behavioral therapies,forgiveness interventions,different meditation approaches,12-step fellowships, and prayerhave provided some evidence,albeit modest, of efficacy inimproving health under specificconditions. Researchers need todescribe spiritual and religiousfactors more clearly andprecisely, as well as demonstratethat such factors independentlyinfluence treatment efficacy.Inclusion of potentialmoderating and mediatingvariables (e.g. extent of religiouscommitment, intrinsicreligiousness, specific religiouscoping strategy) in interventiondesigns could help explainrelationships and outcomes.Using a variety of researchdesigns (e.g. randomized clinicaltrials, single-subjectexperimental designs) andassessment methods (e.g. dailyself-monitoring, ambulatoryphysiological measures, in-depthstructured interviews) wouldavoid current limitations ofshort-term studies using onlyquestionnaires.

Keywords

spirituality, health, intervention,mediating, moderating,variables, research designs

Journal of Health PsychologyCopyright g 1999 SAGE PublicationsLondon, Thousand Oaks and New Delhi,[1359–1053(199907)4:3]Vol 4(3) 413–433; 008807

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a growing body of evidence suggeststhat religious and spiritual involvement is associ-ated with major health outcomes such as all-cause mortality (e.g. Koenig, 1997; Oman &Reed, 1998). Although there has been discussionconcerning possible mechanisms through whichreligious and spiritual involvement may influ-ence health (e.g. Levin, 1996; Miller & Thor-esen, in press), and a small number of studiesthat have controlled for some potentially causalfactors (e.g. Oman & Reed, 1998), little empiri-cal evidence on causal factors exists. The vastmajority of studies to date have been cross-sectional and correlational in nature. While thesesingle occasion ‘snapshots’ can be useful inshowing that a relationship exists between spirit-ual or religious involvement and physical ormental health, the underlying nature of thisrelationship remains largely unexplored andunexplained. We believe that controlled inter-vention studies using experimental designs offermuch promise as a means of understanding thenature of these relationships and possible under-lying mechanisms. Unfortunately, few interven-tion studies have been reported. In a recentreview, for example, only 6 percent of the 148studies examined on religion and counselingvariables were interventions (Worthington, Kur-usu, McCullough, & Sandage, 1996).

The primary goals of this article are as follows:(1) clarify use of terms such as spirituality, reli-gion and health; (2) identify the range of religiousand spiritual interventions currently available orbeing used; (3) review the scientific literatureregarding the therapeutic efficacy of these inter-ventions; (4) identify types of research questionsthat need to be asked when investigating religiousand spiritual interventions in the future; and (5)discuss research procedures for validating theefficacy and effectiveness of interventions withspecific clinical populations. Mentioned but notdiscussed in this article, however, is the specificuse of experimentally designed studies to clarifyand evaluate theoretical explanations (seeThoresen & Eagleston, 1985, for further discus-sion and Andrasik & Holroyd, 1983, for an exam-ple of such experiments involving headacheinterventions and biofeedback theories).

Religion, spirituality, and health

Religion, spirituality, and health are each com-

plex and latent multidimensional constructs. Thesimilarities and differences between them mayvary depending on how they are conceptualizedand operationalized. Given the ambiguity aboutthese terms in many published studies, wecomment here briefly on our use of them.Additional discussion is available in Hill et al.(1997), Pargament (1997), Richards and Bergin(1997), and Thoresen (1998). For the presentpurposes, these terms can be broadly defined inthe following way: spirituality refers a person’sorientation toward or experiences with thetranscendent or existential features of life (e.g.meaning, direction, purpose, connectedness),sometimes referred to as the search for thesacred in life (Larson, Swyers, & McCullough,1998; Thoresen, 1998). That which is sacred canbe thought of as something beyond oneself, suchas a Divine Being, Ultimate Power, CommunalSpirit, or Nature, although a deistic or theisticspirituality is probably most common in westerncultures. Richards and Bergin (1997) viewreligion as ‘denominational, external, cognitive,behavioral, ritualistic, and public’ and thespiritual as ‘universal, ecumenical, internal,affective, spontaneous, and private’ (p. 13).Viewed in this way, religion can be seenprimarily as the external manifestations of spirit-ual experience, although people can engage inreligious activities independent of havingprivate and affective spiritual experiences. It isalso possible to consider oneself intenselyspiritual while not being religious or actuallyanti-religious. From another perspective,spirituality for some can be seen as an attributeof the individual whereas religion can beseen as an organized social entity in whichindividuals share some basic beliefs and prac-tices (Miller & Thoresen, in press). These twoconstructs are probably, but not always, inter-related, and often are used in an interchangeablemanner.

Health also deserves mention as it may beviewed in so many ways, again depending onhow one defines or thinks about it. Despiteconsiderable criticism, some continue to view itas a default concept: health is the absence ofphysical disease or illness (Dubos, 1959; Thor-esen & Eagleston, 1985). We view health to be amore inclusive concept, including a range ofphysical, psychosocial, and sociocultural dimen-sions. We view health as the relative presence of

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positive characteristics, particularly the level ofavailable energy that benefits the individualmentally, physically, spiritually, or otherwise incoping with the demands of daily living (Anton-ovsky, 1979; Miller & Thoresen, in press;Thoresen and Eagleston, 1985). In fact, wesuspect that softening of the traditional andsometimes rigid distinctions between mental,physical, spiritual, and social disease and healthmay facilitate more integrated thinking about theconduct of spiritual interventions.

Secular or religious interventions

Despite the fact that controlled interventionresearch in this area remains in the very earlystages, there appears to be increasing acceptanceof the notion that an individual’s religious orspiritual beliefs and practices may be clinicallyimportant (Richards & Bergin, 1997; Wor-thington, Kurusu, McCullough, & Sandage,1996). Furthermore, support is growing fortherapeutic interventions that are not only sensi-tive to religious and spiritual issues but thatactively utilize patients’ religious and spiritualbeliefs and practices as therapeutic tools (Ber-gin, 1980; Johnson & Ridley, 1992b; Propst,1982, 1988; Richards & Bergin, 1997; Sacks,1985; Spilka, 1986; Stern, 1985; Worthington,1986, 1988). In fact, roughly one-third of medi-cal schools (50 of 125) in the United States nowoffer at least one course related to the role ofspiritual and religious factors in health andmedical practice (Puchalski & Larson, 1998).

The spiritually and religiously oriented inter-ventions described in the published literaturegenerally fall into one of two categories. First,there are interventions that originated in existingsecular theories but make use of religious or spir-itual content in an attempt to alleviate distressand/or strengthen a client’s level of commitment(Richards & Bergin, 1997; Worthington et al.,1996). Johnson and Ridley (1992a) noted thatwhile such interventions retain much of theiroriginal secular form, they are explicitly modifiedso as to: (1) actively promote and utilize clients’religious or spiritual beliefs and practices asagents of change; and (2) be more acceptable toreligious clients. Second, there are those inter-ventions that originated in religious traditions,such as prayer, meditation, and the reading ofsacred texts (Richards & Bergin, 1997).

In the first category, religious and spiritualcontent are placed into existing psychologicalinterventions, while in the second category, reli-gious and spiritual content and practices areviewed to be therapeutically independent of sec-ular psychosocial theories. This distinction maybe more theoretical than practical. For example,forgiveness and prayer/meditation-based inter-ventions can actually be explained and justifiedtheoritically either psychologically or throughtraditional religious practice.

Propst (1980, 1982, 1988) suggests a compel-ling reason for the usefulness of religious inter-ventions. A religious or spiritual person maylook at the world through a religious or spiritualschema or use religious language or metaphor asa cognitive construction of the world. This viewmay be different from the therapist’s world view(Bergin, 1980), and these differences may pres-ent significant barriers to effective treatment.Shafranske and Malony (1996) make a persua-sive argument for the inclusion of religiousissues in the clinical practice of psychologybased on four rationale: ‘the professional ideal ofcultural inclusion; the substantial evidence ofreligion as a cultural fact; the developing body oftheoretical, clinical, and empirical research lit-erature concerning religion as a variable in men-tal health; and the appreciation of psychologicaltreatment as a value based form of intervention’(p. 561).

What is the evidence?

Virtually no well-controlled intervention studieshave yet focused primarily on changing a spirit-ual or religious factor, that is, none have usedsuch factors as the major focus or dependentvariable of an intervention. Nor have spiritual orreligious factors served as the main interventionor treatment (Levin, 1994; Thoresen, 1998),with the exception of intercessory prayer inter-ventions (e.g. Byrd, 1988). Rather, most of thereligious or spiritual interventions developedand employed to date have simply been tech-niques imported from formal religious traditionsand used as adjuncts to standard clinical treat-ments for religious clients or patients (Wor-thington et al., 1996). Some studies have usedwhat has been traditionally a spiritual or reli-gious practice, such as meditation, in a sec-ularized form within a controlled research

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design to change psychological or physicalhealth factors (e.g., Kabat-Zinn et al., 1998).Other health interventions have occasionallyincluded what could be termed a spirituallyfocused component, such as forgiveness, amongseveral other treatment components (e.g. Fried-man et al., 1986; Ornish, 1990; Ornish et al.,1998; Propst, Ostrom, Watkins, & Dean, 1992;Spiegel, Bloom, Kraemer, & Gottlheil, 1989).However, these components have not beenexplicitly operationalized as being spiritual, norhave their independent contributions to treat-ment outcomes yet been assessed or evaluated.

Support for the effectiveness of religious andspiritual interventions remains largely theoret-ical (e.g. Aldridge, 1993) or based on eithersingle case or small sample designs (e.g. Al-Mabuk & Downs, 1996). Thus, the lack oflarger studies seriously limits the generaliz-ability of these results to other patient popula-tions or clinical settings.

Despite the general lack of empirical evidencethat some religious or spiritually oriented treat-ments are effective or superior to non-religioustreatments in working with religious clients(Johnson & Ridley, 1992b; McCullough, 1999;Worthington, 1986), a plethora of articles andbooks has begun to emerge describing approa-ches to religious and/or spiritual therapy (e.g.Miller, in press; Richards & Bergin, 1997;Shafranske, 1996). Table 1 lists the major

religious/spiritual interventions that are cur-rently in relatively widespread use either inpastoral counseling, clinical/counseling psychol-ogy, or medical settings.

Unfortunately, a tendency exists among clin-ical advocates of some approaches to makesweeping claims of treatment effectivenesswithout evidence gathered in well-controlledtreatment studies (e.g. Backus & Chapian, 1980;see Ellison & Levin, 1998, for further discus-sion). In particular, treatment approaches haveseldom been specifically evaluated as to whetherthe persons being treated benefited from thereligious or spiritual features of the interventionper se or whether the intervention was moreeffective than standard clinical treatment. Thefollowing sections discuss the available lit-erature on the efficacy of the five religious/spiritual interventions for which some empiricalevidence is available: (1) adapted cognitive–behavioral interventions; (2) meditation; (3)12-step fellowships; (4) forgiveness inter-ventions; and (5) prayer. A comprehensivereview of the literature in these areas is notattempted. Rather, we focus on the evidence thatspiritual or religious components of these inter-ventions contributed therapeutic value, espe-cially when compared to standard treatments orsecularized interventions. Recommendations forfuture research in each of these areas are alsooffered.

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Table 1. Spiritual and religious interventions currently in use

Interventions that may exist in secular or spiritual/religious form

Interventions that are inherently spiritual or religious

Forgiveness therapy Religious/spiritual dance

Willingness, releasing, letting go Prayer(Fleischman, 1986)

Cognitive–behavioral approaches Religious/spiritual bibliotherapy(Richards & Bergin, 1997)

Ritual

Meditation/contemplation Referral to religious or spiritual leaders

Service, volunteering (‘selfless service’)

Development of a personal (spiritual or existential)philosophy

Utilization of religious community as a resource

Twelve-step fellowships Spiritual or religious assessment

Spiritual confrontation(Richards & Bergin, 1997)



Cognitive–behavioralinterventions

Cognitive–behavioral therapy (CBT) has beenfound to be an effective treatment for clinicaldepression and other mood-related disorders byhelping clients to change thinking processes(e.g. automatic thoughts) and also their ineffec-tive ways of responding to stressful stimuli(Chambless et al., 1996). Cognitive–behavioralinterventions typically involve teaching andcoaching clients or patients to alter specificthoughts and behaviors in ways that make themfeel better, reduce symptoms, and alter theperceived causes of the problems. The client isintroduced to the concept that thoughts, beliefs,and interpretations of life events strongly influ-ence the way the client functions physically,emotionally, and socially. Beliefs, for example,are often challenged and described as malad-aptive, irrational, or simply based on inadequateevidence (e.g. McMullin, 1986). As clients learnto influence their symptoms and affective statesthrough changing thoughts, beliefs, and behav-iors, they are viewed as gaining a greater senseof autonomy and self-efficacy to maintain orimprove their mental and physical health (seeBeck, 1995).

To date, only five psychotherapy outcomestudies have evaluated the relative efficacy ofcognitive–behavioral interventions modified tobe more spiritually or religiously focused com-pared with unmodified versions. All of thesestudies have been conducted with clients whoidentified themselves as religious (Johnson,DeVries, Ridley, Pettorini, & Peterson, 1994;Johnson & Ridley, 1992b; Peucher & Edwards,1984; Propst, 1980; Propst et al., 1992). Each ofthese studies modified an established cognitive–behavioral intervention to be congruent with thereligious beliefs of Christian clients. However,no studies have evaluated such modificationswith persons of other religious or spiritualorientations nor have any studies demonstratedthat more religiously or spiritually focused CBTinterventions provide better results than standardtherapies for clients in general, that is, withreligious and non-religious clients.

Only Propst (1980) and Propst et al. (1992)have found a religiously adapted CBT approachto be more effective with religious clients than asecular version. Specifically, Propst (1980)

found that religious imagery treatment within aCBT approach produced statistically significantlower levels of depression on both self-reportand behavioral measures than non-religiousimagery.

In the most comprehensive and well-con-trolled outcome evaluation to date, Propst et al.(1992) found that religious clients in a pastoralcounseling CBT treatment group with religiouscontent, reported significantly less post-treat-ment depression and maladjustment than didreligious clients in regular CBT treatment orwait-list control group. The authors did reportanother noteworthy (and unexpected) finding:religious clients receiving CBT with religiousimagery from non-religious therapists actuallyhad lower levels of depression and maladjust-ment scores than patients receiving the sametreatment from religious therapists. This unex-pected finding, although possibly explained bysampling error, suggests that several factors mayinteract significantly in interventions and need tobe studied using appropriate research designs.

On the other hand, Peucher and Edwards(1984), using a Christian version of Beck’s cogni-tive therapy for depression, reported no signifi-cant differences between secular and Christianversions of the treatment in reducing depressionfor religious clients. More recently, Johnson andRidley (1992b) and Johnson et al. (1994) evalu-ated the comparative efficacy of Christian ver-sions of Ellis’ rational–emotive therapy with asecular version. Results demonstrated that bothtreatments significantly reduced depression, auto-matic negative thoughts, irrational thinking, andgeneral psychopathology. No consistent differ-ential treatment effects were found. Thus, presentempirical support for adapting CBT to fit reli-gious clients remains modest and mixed. In arecent review and meta-analysis, McCullough(1999) concluded that the choice to use reli-giously orientated therapies with religious clientswas more a matter of client preference rather thanan issue of differential efficacy.

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Some areas that need to be addressed in futureresearch include the following: (1) Evidence isneeded regarding religiously or spiritually mod-ified forms of CBT with different problem areasand different populations; (2) Detailed informa-tion should be gathered about the diversity ofmeanings people hold about pertinent categor-ical variables, such as Christian (or Jewish,



Hindu, etc.) and Religious. Each of these groupsundoubtedly represents considerable diversitywith respect to religious/spiritual thoughts,beliefs, and behaviors. Much more carefulassessment of the multiple dimensions of gen-eral religious and spiritual orientations (Miller &Thoresen, in press) would help clarify whoresponds most to a specific kind of religiouslyadapted treatment and may also shed light onunderlying mechanisms of treatment responses(see Pargament et al., 1999, and Woods, Antoni,Ironson, & Kling, 1999, this issue, for examplesof the importance of discerning between dif-ferent styles of religious coping among Chris-tians). (3) We need to know how well thesetherapies work for people with different reli-gious or spiritual frameworks, as well as forpeople who do not consider themselves religiousor spiritual. Based on Kiesler’s (1966) critiqueof problems in psychotherapy research, Thor-esen (1998) has warned of the dangers ofuniformity myths in spiritual and healthresearch, such as assuming that all ‘religious’clients are essentially the same (patient uni-formity myth), and that all religious clients witha particular diagnostic problem need the sameintervention (treatment uniformity myth).

Meditation-based interventions

Although a highly cognitive and sometimesemotional activity, meditation immerses thewhole person in a psychophysiological experi-ence, which has been characterized as ‘activepassivity’ (e.g. sitting quietly while beinginwardly alert and focused) and ‘creative quies-cence’ (e.g. inwardly calm while being open toexpanded awareness) (Shafii, 1985, pp. 90–91).This calm yet alert attentiveness is practiced intwo basic forms (Carrington, 1993; Goleman,1988; Odajnyk, 1993). One is concentration, orfixed meditation, in which the person focusesawareness on an internal or external object (e.g.sound, word, breath) while minimizing distrac-tion and bringing the wandering attention backto focusing on the chosen object. The secondmeditative practice is known as mindfulness, inwhich the person focuses alertly but non-judg-mentally on all processes passing through themind, not on a fixed object, thought, or action(Goleman, 1988; Kabat-Zinn, 1993).

Meditation has been more frequently associ-

ated with eastern religions (e.g. various forms ofHinduism and Buddhism) and often more nar-rowly with transcendental meditation (TM).However, meditation with a religious/spiritualorientation is deeply rooted and extensivelypracticed in western religions as well (Benson,1993; Goleman, 1988; Schopen & Freeman,1992). When divested of its spiritual and reli-gious elements, meditation also serves as atherapeutic method with similarities to biofeed-back techniques, progressive muscle relaxation,visualization, and guided imagery techniques(Carrington, 1993; see Kristeller & Hallett,1999, this issue). Indeed, during the past 20years, meditation has been extensively studiedas a way of reducing physiological and psycho-logical stress (e.g. Benson, 1996). While thereare several forms of meditation, all appear toproduce similar physical and psychologicalchanges (Benson, 1975; Chopra, 1991; Eas-waran, 1989; Goleman, 1977; Yogi, 1963)

Since the early 1960s there has been agrowing interest in the use of Hindu- andBuddhist-based meditation as interventions forvarious types of psychological and physicalhealth problems. More recently, research hasfocused on the use of meditation as an adjunct toconventional therapy models for alcohol andsubstance abuse treatment as well as the allevia-tion of pain, depression, and the symptoms ofheart disease (see Ornish et al., 1998; Shapiro &Walsh, 1984; Smith, 1975 for reviews of theliterature on this topic).

For example, Gelderloos, Walton, Orme-Johnson, and Alexander (1991) reviewed 24studies on the benefits of TM in treating andpreventing misuse of chemical substances.These studies examine the effect of TM withnon-institutionalized users, participants in treat-ment programs, and prisoners with histories ofheavy substance use. Most studies generallyfound positive effects for the TM program.Some of the survey-based studies were unable toexclude the significant possibility of self-selec-tion or response biases in explaining results.Gelderloos et al. (1991) concluded that TMprograms simultaneously addressed several fac-tors underlying chemical dependence, providingnot only immediate relief from distress but alsoenduring improvement in well-being, self-esteem, personal empowerment, and other areasof ‘psychophysiological health’.

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Meditation as part of complextreatmentsOrnish and his colleagues (e.g. Ornish et al.,1998) conducted an intervention called theLifestyle Heart Trial in which patients withconfirmed heart disease were placed on adietary and lifestyle modification program. Inaddition to significantly reducing the dietaryintake of fat, Ornish et al. (1998) also incorpo-rated moderate aerobic exercise, meditation,yoga, and group counseling into a treatmentprotocol to reverse coronary artery diseasewithout using pharmacological or surgicalinterventions. Dramatic reductions in physicalsymptoms and improved overall health werefound in addition to a reduction in coronaryartery occlusion for most patients in the experi-mental group. By contrast, patients in the usualcare group showed significantly more progres-sion of coronary artery disease, having 20percent more plaques than the treatment group.Although Ornish contends that the meditationcomponent of this regimen was integral tooverall success, the individual components ofthis multifaceted program have not been dis-tinctively evaluated. Therefore, it is uncertainyet as to how much, if at all, the meditationcomponent contributed to the observed improve-ments in artery disease, physical symptoms, andpsychosocial factors.

Relaxation responseSome have suggested that most of what can beaccomplished therapeutically with meditationcan be accomplished with relaxation training,which is generally easier to embrace for thosewho are reluctant or concerned about the reli-gious basis of some meditation practices (Wor-thington et al., 1996). In the 1970s, cardiologistHerbert Benson identified what he called therelaxation response as one of the effects ofvarious types of meditation (Benson, 1975).Benson’s research over the years has examined awide constellation of psychological and physio-logical effects of the relaxation response (seeBenson, 1996; Benson, Malhotra, Goldman, &Jacobs, 1990). In order to elicit the relaxationresponse, one focuses on a repetitive prayer,word, sound, image, or muscular action (e.g.breathing), which allows the person to reduceexternal distractions. Interestingly, when given achoice, many individuals prefer to use a ritual

prayer from their family of origin when practic-ing relaxation (Benson, 1996).

If the relaxation response is a component ofvarious meditative practices and prayer, thisraises important theoretical questions regardingthe mechanisms by which these interventionsmay work. Are the spiritual or religious compo-nents of various meditative practices in essence‘delivery systems’ for the actual mechanism ofchange, that is, the relaxation response? Or dothe spiritual or religious components, whenpresent, contribute to observed effects of medi-tative practice in a more integral or facilitativeway, allowing the relaxation response to work ina way that otherwise could not or would nothappen? Or do the spiritual and religious com-ponents act as an additional and separate ‘activeingredient’? Furthermore, are these relationshipsdifferent for different people? Whether therelaxation response is the primary mediator ofthe effects of meditation or prayer is stillunclear. It should be noted that some questionthe overall evidence to date that claims tosupport the efficacy of the relaxation response inhealth care (see Roush, 1997).

Comparing types of meditationAlexander, Langer, Newman, and Chandler(1989) conducted one of the few studies to datethat compared TM, mindfulness meditation(MF), and relaxation training. In addition, anassessment control condition was used. All wereassessed in terms of short-term mortality ratesand reversing age-related declines in physicalhealth. To accomplish this, 73 residents of eightnursing homes (mean age 81 years) were ran-domly assigned to one of the four conditionsmentioned above.

After 36 months, the TM group was foundmost improved on measures of cognitive andbehavioral flexibility, mental health, and systolicblood pressure, followed by the MF group, therelaxation group, and the assessment controlgroup, respectively. By contrast, the MF groupimproved the most on perceived control andword fluency, followed by the TM group, therelaxation group, and the assessment controlgroup, respectively. After 3 years, the survivalrate for the TM group was 100 percent com-pared to 87.5 percent for the MF group, 65percent for the relaxation group, and 62.5percent for the assessment control group.

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This study suggests that the effects of medita-tion on physical and mental health may gobeyond merely enhancing one’s ability to relaxand reduce physiological stress. Recently, anumber of studies, some controlled clinicaltrials, have used meditation as the primarytreatment variable (e.g. Astin, 1997; Maclean etal., 1997; Miller, Fletcher, & Kabat-Zinn, 1995;Panjwani, 1995; Vedanthan et al., 1998; Wenne-berg et al., 1997). The results suggest thatalthough meditation is not a panacea, it may befor certain clinical populations an effective, non-invasive, and cost-effective adjunct or alter-native to other therapies. Future research in thisarea should focus in on comparing explicitlyreligious or spiritually oriented meditation inter-ventions with more secularized versions, assess-ing dimensions of participants’ religious andspiritual orientation, and paying much moreattention to selected individual treatment inter-actions that may moderate or mediate clinicaloutcomes (e.g. gender and type of religiousaffiliation).

Twelve-step fellowshipsTwelve-step fellowships address themselves tohelping people whose lives are damaged by theexcessive consumption of alcohol or drugs(Scott, 1993; Trice & Staudenmeier, 1989) andmore recently by a broad range of humanproblems with excessive dependence or addic-tive features (e.g. gambling, overeating, sexualaddiction). Twelve-step fellowships have bur-geoned in the past few decades and today areconsidered by many to be a very successfulmethod for supporting sobriety (e.g. Emrick,Tonigan, Montgomery, & Little, 1993). Esti-mates put membership in Alcoholics Anony-mous (AA) alone at about 500,000 membersworldwide. A thorough review of the researchevaluating 12-step fellowships is not possiblehere. Instead, we focus on the evidence thatspiritual and religious features of 12-step fellow-ships are instrumental to their successful out-comes.

Alcoholics Anonymous, the original 12-stepmovement, is explicitly based on transcendentspiritual principles (e.g. ‘God as you knowhim’). AA writings assert the existence andimportance of spiritual processes and the rele-vance of the spiritual process with clinicaloutcomes (Brown, 1985; Brown, Peterson, &

Cunningham, 1988; Johnson & Chappel, 1994).It is through an emphasis on surrender to ahigher power, self-honesty, patience, tolerance,kindness, and humility that spiritual growth ispresumably encouraged in AA. Studies haveconcluded that active AA membership enablesfrom 60 to 68 percent of alcoholics to drink less(or not at all) for up to a year, and 40 to 50percent to achieve sobriety for many years(Emrick, 1987). Although there is some evi-dence that more active or dedicated membersremain sober longer, other researchers havefailed to find a dose–response relationship (Wat-son, Hancock, Gearhart, & Mendez, 1997).

Several theories attempt to explain the suc-cess of the AA approach. One model interpretsthe achievement of sobriety as a ‘conversionexperience’ (Galanter, 1990; Greil & Rudy,1983). However, an alternative model suggeststhat AA members recover by learning andpracticing a better way to handle their addictivedisorder or ‘disease’ and also to live morehealthy lives (Hufford, 1988; Kurtz, 1982; Scott,1993). In contrast to the ‘conversion experience’theory, this model describes learning the ‘newway’ through an intellectual and educationalprocess requiring considerable therapeutic workand perseverance (Kurtz, 1982). AA’s owntheory suggests that its success comes from thecommitment to a group and surrender to ahigher power. Clearly, AA offers a complexintervention with several components.

Some authors argue that despite decades ofexperience, appropriate controlled outcomestudies of 12-step fellowships have not beendone (Peele, 1990). In addition, issues have beenraised about more appropriate research designs,such as comparing the effects of 12-step fellow-ships to other recognized interventions, andabout assessment issues, such as assessing psy-chosocial functioning more frequently beforeand after 12-step participation (Glaser &Ogborne, 1982). Of particular theoretical inter-est would be the comparison of the spirituallybased 12-step programs with a program, such asRational Recovery (Schmidt, 1996), that is anon-spiritual or secularized version of AA pro-grams. Also of interest is the relative importanceof the spiritual element in AA programs, inde-pendent of other factors in the AA model knownto facilitate change (e.g. perceived social andemotional support). Other questions have been

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raised but not adequately addressed, includingthe possible benefits of tailoring the type ofspiritual or religious focus (e.g. type of religiouscoping method) to various person factors (e.g.position on an intrinsic–extrinsic religiosity con-tinuum) (Gorsuch & Miller, in press; Pargament,1990). Given their popularity and their apparentsuccess rates, additional research on 12-stepfellowships seems long overdue. For an exten-ded discussion of this topic, the reader isreferred to Miller and Bennett (1998).

Forgiveness interventionsHelping clients forgive is often a major focus oftherapeutic work (Denton & Martin, 1998;Jones, Watson, & Wolfram, 1992). Some arguethat forgiveness is the most frequently usedspiritual intervention used by psychotherapists(Richards & Bergin, 1997). Unlike prayer, for-giveness has commonly been used in secularcounseling by non-religious counselors and cli-ents alike, particularly in individual, martial, andfamily therapies (see Al-Mabuk & Downs,1996; DiBlasio, 1992, 1993, 1998; DiBlasio &Benda, 1991; DiBlasio & Proctor, 1993). For-giveness appears to be a therapeutic conceptthat, like meditation, can be used with orwithout reference to spiritual or religious beliefs(McCullough, Sandage, & Worthington, 1997;Richards & Bergin, 1997).

Some case studies of the effectiveness and theprocesses of forgiveness have been reported(e.g. DiBlasio, 1998; Flanigan, 1992) along withcountless anecdotal reports (e.g. Albom, 1997).A number of theoretical articles about possibletherapeutic processes involved in forgivenessare also available (e.g. McCullough, Pargament,& Thoresen, in press; Worthington, 1998).However, fewer than 20 forgiveness interven-tion studies have been reported (e.g. Al-Mabuk,Enright, & Cardis, 1995; Coyle & Enright,1997; Freedman & Enright, 1996; Hebl &Enright, 1993; McCullough & Worthington,1995; McCullough, Worthington, & Rachal,1997; Rye & Pargament, 1997).

These studies have provided encouraging evi-dence that people can reduce their levels of self-reported hurt, anger, and perceived offense, andhave improved their self-reported mood andemotional states. Only one study by Rye andPargament (1997) to date has studied a reli-giously integrated forgiveness intervention and

compared it with a secularized version and a no-treatment control group. In this study bothintervention groups demonstrated positivechanges in hopefulness, existential well-being,and forgiveness, as well as other dimensions,compared to the control group. However, thereligious and secular treatments did not differ inefficacy. No forgiveness intervention study hasyet assessed physiological variables or reportedimproved physical health or disease-relatedchanges (Thoresen, Harris, & Luskin, in press).

Intervention-related issuesRecently much has been written concerningissues that need to be addressed in futureforgiveness research (see McCullough, Parga-ment, & Thoresen, in press). Worthington, San-dage, and Berry (in press), Thoresen et al. (inpress), and Thoresen, Luskin, and Harris (1998)have offered extended discussions of researchissues concerning forgiveness-based interven-tions. As mentioned, forgiveness shows genuinepromise as a therapeutic goal. What remainsunknown is the therapeutic impact of integratingreligious or spiritual elements into forgivenessinterventions. What should be integrated and forwhich persons? We do not know how religiousor spiritual elements may interact with thereligious or spiritual characteristics of partici-pants. For example, would a more universallyfocused spiritual framework result in betteroutcomes for some Christians (or those ofanother religious orientation) than one focusedspecifically on a Christian perspective?

Another theoretical issue pertaining to bothreligious and secular forgiveness interventions isthe question of prematureness. Richards andBergin (1997) note that it is important not toencourage premature forgiveness, suggestingseveral possible consequences of doing so, suchas failing to fully recognize the nature of theoffense and the need to focus first on protectingagainst future offenses.

Another major question deserving more studyis the view that successfully forgiving an offen-der requires (or is mediated by) an increase inempathic understanding of the offender by theperson hurt (e.g. McCullough et al., 1997). Canpeople experience health benefits by forgivingothers but not alter in any substantial manner, ifat all, their empathy for them? Or is increasedempathy for the offender the key active ingre-

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dient in forgiving and thus in mediating healtheffects for the forgiver? Research that exploresthese and other conceptual notions of forgive-ness could greatly contribute to our under-standing of this topic (see McCullough et al.,1997).

Seeking forgivenessAlthough the ability to forgive another may beimportant in fostering improved interpersonalrelationships and mental health, seeking forgive-ness when one has wronged another could alsoprove important in improving relationships.Only a few empirical studies of seeking forgive-ness have been reported in the social psycho-logical literature (Bassett, Hill, Pogel, & Lee,1990; Cody & McLaughlin, 1988; Weiner,Graham, Peter, & Zmuidinas, 1991), but noclinical investigations have been undertakenusing this type of intervention. Does, for exam-ple, combining forgiving another with self-forgiveness in an intervention yield better out-comes, particularly over time? It would also beuseful to begin to compare the various forms offorgiveness therapy in specific clinical popula-tions (e.g. mildly, moderately, and severelydepressed individuals) to determine which for-giveness approaches result in greater benefits.Controlled intervention studies with personsfrom various age, ethnic, clinical, and socio-economic groups, as well as different religious/spiritual orientations would also begin to clarifywhat works better with whom in particularproblem areas.

Exline, Yali, and Lobel (1999, this issue)present, for example, a study that raises anotherfascinating and potentially useful perspective onforgiveness interventions: the notion of forgiv-ing God. What are the benefits and contra-indications of promoting forgiveness of a DivineBeing or an Ultimate Source in therapeuticwork? What are the client and therapist factorsthat might make this type of intervention bene-ficial or detrimental? These questions are worthyof further study.

Prayer

Researchers attempting to study the effective-ness of prayer in naturalistic settings havedocumented its importance in religious peopleas a method of coping with stress or stressful

situations (e.g. Pargament, 1990). It has alsobeen observed that prayer is not a unitaryphenomenon, and as such can vary by purpose,formality, the object and subject of the prayer,and its attendant behaviors and circumstances(Richards & Bergin, 1997). Prayers can begeneral or specific, for oneself or others, to aspecific God or offered more generally. Richardsand Bergin (1997) cite preliminary evidencesuggesting that different forms of prayer mayhave differential associations with certain out-come variables, such as overall well-being andlife satisfaction. However, the usefulness ofprayer as adjuncts to counseling or medical careremains almost completely uninvestigated (Mar-wick, 1995; Worthington et al., 1996).

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Intercessory prayer: an exampleIn the first well-designed empirical study of theeffectiveness of intercessory prayer (i.e. askingGod or a divine power to intercede on another’sbehalf) on physical health, Byrd (1988) assigneda group of three to seven Christians to pray forpatients (n 5 393), primarily recovering fromacute myocardial infarction, over a 10-monthperiod. Patients were assigned randomly to oneof two groups: a prayer or a non-prayer group.In the prayer group, patients were prayed for butdid not know they were being prayed for. Thosewho prayed knew the patient’s first name,specific diagnosis, and general condition; theyreceived periodic updates on the patient’s condi-tion. Each patient was prayed for by betweenfive and seven people at least once a day. Thosepraying were not given explicit instruction abouthow to pray. The praying was done outside thehospital. In the no-prayer control group, patientswere not assigned to people for daily prayer(although they may have been prayed for byfamily members or friends). Because this studyemployed a double-blind design, neither thepatients nor the researchers who collected andanalyzed the outcome data knew who in thestudy was in the prayed-for group.

Results showed that patients in the prayercondition did substantially better than controlpatients on a number of health-related outcomecategories at the experiment-wide p < .05 level,such as 7 percent fewer antibiotics required atdischarge (p < .005) and 6 percent less need forintubation (p < .002). In addition, they had 6percent less pulmonary edema (p < .03), 6



percent less congestive heart failure (p < .03),and 5 percent less cardiopulmonary arrest (p <.02), although these differences failed to reachstatistical significance at the experiment-wide p< .05 level.

This double-blind clinical trial appears tohave been generally well designed with suffi-cient statistical power to detect important differ-ences. The generalizability of its findingsdepends, however, on replication by others.Furthermore, the study had some methodo-logical weaknesses. For example, participantswere not matched on several potentially relevantvariables, such as their own religiousness. Fur-thermore, no effort was made to assess theamount of prayer offered for patients in the no-prayer group (e.g. by family members, friends,and even the patients themselves).

The findings of this study need to be viewedwithin the context of other empirical investiga-tions of prayer of different kinds, not all ofwhich have demonstrated significant effects (seeBenor, 1990 for a review of spiritual healingresearch, including intercessory prayer). Theissues of how to explain these findings (e.g. bywhat mechanism might intercessory prayerwork?) also looms large, making it difficult forsome to take any clinical results seriously(Thoresen, 1998). Nevertheless, this double-blind study did yield statistically and clinicallysignificant results. At the very least, thesefindings merit efforts to replicate and clarifypossible factors that might explain such results.

Another intercessory prayer study merits briefcomment, given the Byrd (1988) findings. Sicher,Targ, Moore, and Smith (1998) recently reportedfindings from a randomized double-blind study of40 AIDS patients. Each of 20 randomizedpatients was prayed for over 10 weeks by 10different prayers, all recognized as professionalhealers from several religious and spiritual tradi-tions throughout the United States. All prayershad extensive experience in using intercessoryprayer, sometimes termed distant healing. Noneof the participants in the study knew if they werein the prayer or no-prayer condition.

Those in the prayed-for condition differedsignificantly over 6 months from the controlcondition on various physical health-related out-comes. For example, total number of hospital-izations was 3 compared to 12 (p < .05), numberof outpatient physician visits was 185 compared

to 260 (mean visits 9.2 compared to 13.0, p <.01), number of days in the hospital was 10compared to 68 (p < .05), and the number ofnewly acquired AIDS-related diseases was 2compared to 12 (p < .05). No differences werefound, however, for CD4 cell counts or in mor-tality (all were on protease inhibitors and othermedications which have sharply reduced AIDSmortality). Also, because more than 30 of thecomparisons in this study were made usingpaired t-tests or Wilcoxon signed-rank test, theexperiment-wide error rate appears to be quitehigh. Interestingly, improvements in self-repor-ted emotional mood were also significantlyhigher in the prayer condition.

Richards and Bergin (1997) mention severalways to incorporate prayer into a treatmentregime. These include encouraging a person topray, praying with the person, praying for theperson, asking others to pray with or for theperson, and possibly other forms. These authorsdiscuss potential ethical and role boundary issuesthat need to be addressed, however, when con-sidering use of prayer in treatment. Theseinclude the danger of imposing certain beliefs orvalues on clients, usurping or conflicting withreligious authority, and the possibility of ‘poten-tially unhealthy transference issues’ (p. 204).

Overall, further research is needed to clarifythe efficacy of prayer in altering clinical out-comes. Furthermore, the costs, benefits, andappropriate therapeutic uses of various forms ofprayer need to be considered. Use of qualitativeinterview studies of clients whose treatment hasinvolved some form of prayer could be used tocomplement the kind of knowledge gained fromcontrolled intervention studies in this area. Notethat prayer may indeed prove to be very bene-ficial for some persons with various health prob-lems, even though we may be able to explainsome but not all of the mechanisms of howprayer functions to influence health. We believethat a critical yet open-minded perspective iscalled for, recognizing that at present manyuseful health and medical procedures cannot befully explained as to what specific mechanismsactually account for the observed changes(Suppe, 1977).

Guidelines for future research

Johnson (1993) presented some guidelines that

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seem useful for future research on religious andspiritual interventions. These guidelines are pre-sented as a series of six questions that research-ers and practitioners of religious and spiritualtherapies could use to guide the development,validation, and comparison of different treat-ment approaches. These six questions as well astwo others are presented here for consideration.

Question 1: what is it?Most theorists in the field have neitheradequately explained their assumptions noroperationalized their therapeutic constructs andmethods, including relevant independent vari-ables that need to be included and measured inthe research (Johnson & Ridley, 1992b; Thor-esen, 1998). Therefore, prior to conductingempirical research on any religious or spiritualintervention, the treatment needs to be carefullyoperationalized. Specifically, researchers shoulddevelop treatment manuals to fully describe thetreatment package, even if these manuals arerough ‘first editions’. Such manuals can help toensure treatment consistency within and acrossresearch studies, as well as encouraging othersto conduct needed research.

Researchers also need to clarify potentialclinical factors that are possibly influenced bythe treatment. For example, how do the spiritualelements of an intervention interact with spirit-ual beliefs and practices of participants to reducespecific symptoms? In conjunction with thisdocumentation, researchers can also offerdetailed clinical case histories that describepresumably critical features of the treatment asit is practiced and experienced with specificclients of different religious and spiritual tradi-tions with certain problems. The question of‘what is it?’ may best be answered by usingdifferent research strategies and assessments, apoint that applies to other questions cited below.See Thoresen (1998) and Thoresen, Luskin, andHarris (1998) for further discussion of how theexperience of researchers in counseling andpsychotherapy can be especially useful for spir-itual and religious interventions. See, also, Elli-son and Levin (1998) on other perspectivesabout what needs to be studied in this area.

Question 2: does it work?The efficacy of an intervention in terms of itsoverall main effect should be established prior

to employing complex, multitreatment compar-ative designs. At this initial ‘does it work’ stage,the following designs could be employed,although the specifics of these designs as well astheir strengths and limitations are not elaboratedhere (see Cook & Campbell, 1979; Hillard,1993; Kazdin, 1982): One Group Pre-test–Post-test Design, Randomized Control Group Pre-test–Post-test Design, and Single Subject Exper-imental Designs. Furthermore, methods ofqualitative inquiry (see Denzin & Lincoln,1998), such as interview data, and daily mon-itoring methods (see, for example, Keefe et al.,1997) can also effectively complement moretraditional means of assessment (e.g. standar-dized questionnaires). Qualitative methods alsooffer considerable potential to strengthen anddeepen the nature of empirical evidence, byacting as validity checks to standardized self-report measures, and in revealing phenomenarelated to effects and correlates of interventionsnot available otherwise (see, for example,Richards & Folkman, 1997, and Fow, 1996 aswell as Shedler, Mayman, & Manis, 1993, onthe dangers of only using questionnaires whenassessing sensitive social and emotional topicsand issues).

Question 3: how does it compare?After a religious or spiritual intervention hasbeen established as being generally efficacious,it is then useful to compare it to other treatmentmodalities. Alternatively, once secular versionsof a therapy have been shown to be effective(e.g. CBT or meditation), then religiously orspiritually integrated or adapted versions can becompared to ‘standard treatment’. At least twostate-of-the-art research designs can be utilizedto accomplish this: Non-randomized Two GroupPre-test–Post-test Design and Randomized TwoGroup Pre-test–Post-test Design (Cook &Campbell, 1979). The latter design is moredesirable for initial comparative outcome evalu-ation because it offers better control of otherpossible explanations as to why an interventionmight be successful (see Alexander et al., 1989and Propst et al., 1992, for examples).

Question 4: what are the criticalingredients?When an intervention has been shown to pro-duce consistent therapeutic benefits, Kazdin

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(1986) recommends use of two further evalu-ation strategies aimed at analyzing the basis forsuch change. The first is called a ‘dismantlingstrategy’, in which the individual components ofthe treatment are eliminated step by step untilthe necessary and sufficient components of thetherapeutic change have been determined. Thesecond design is termed a ‘constructive strat-egy’, in which an additive approach is used todetermine how many components of the inter-vention need to be added to achieve meaningfuloutcomes.

Dismantling and constructive approaches areconsidered appropriate only after a treatment hasfirst been shown to be generally effective. Theseapproaches are aimed at trying to clarify atreatment’s ‘active ingredients’ and avoiding useof more components than are needed. Thoresen,Luskin, and Harris (1998), for example, calledfor a stepped-care intervention approach inforgiveness interventions. Some people suffer-ing from unresolved hurt or offense by othersmay only need written information about how toforgive; others may need such information plusopportunities to meet occasionally with otherswho are also trying to let go of the burden ofpast hurts. Still others may need the above plusmeeting with a trained health care professional.Spiritual and religious factors may be compo-nents that are included for some people atcertain steps. Determining who, particularlyamong the spiritually or religiously committed,needs what steps of an overall treatment can beexamined using a constructive or stepped-careapproach (Black & Coster, 1996). This modelhas great potential in avoiding the costs associ-ated with providing complex treatments; typi-cally not everyone needs the complete range ofintervention components (e.g. Robin, Gilroy, &Dennis, 1998).

Question 5: how does it interactwith other variables?Researchers also need to examine possible inter-actions among patient, therapist, and treatmentvariables across treatment packages (Beutler,1979; Butler & Strupp, 1986; Critis-Cristoph &Mintz, 1991; Stiles, Shapiro, & Elliot, 1986).One solution for doing this is to undertakeresearch using ‘matrix’ designs (Stiles, Shapiro,& Elliot, 1986), which seeks to understand howtherapist qualities interact with patient charac-

teristics to produce (or fail to produce) theinterpersonal conditions necessary for thera-peutic change (Butler & Strupp, 1986). In thisdesign, single interventions might be evaluatedwith one or more patient, therapist, or environ-mental variables completely nested. For exam-ple, a religious modified CBT might be admin-istered, varying therapist religiosity acrosstreatment groups. Or an intervention with a non-specific spiritual orientation might be admin-istered to participants who vary in religious orspiritual orientation, including persons who arenot religious or spiritual. Again, it is oftenimportant to assess for multiple dimensions ofreligious or spiritual involvement and not solelyrely on one single dimension or factor, such asfrequency of church attendance.

For example, Oman, Thoresen, and McMahon(1999, this issue) found that men and womendiffered in how much they benefited in reducedmortality rates from volunteering to help others.Gender produced differences that interacted withthe effects of being of service to others. Why didmen only show benefit if they volunteered tohelp in at least two organizations when womengained from one or more? Reasons for thisdifference remain unclear. Most likely, otherfactors covaried among the men in this study toreduce the effects of volunteering.

Question 6: when and where shouldit be evaluated?Researchers need to conduct clinically mean-ingful outcome evaluations in order to provideexternal or clinical validity for interventions,making the case that treatment generalizes topeople under varying conditions (e.g. differentethnic groups, different religious backgrounds,different types of problems). Studies conductedto date in this area have generally been analogstudies as opposed to clinical trial research, withthe latter being more generalizable. Single-caseexperimental designs and experimental processresearch can also help in exploring generaliz-ation issues (Shapiro & Shapiro, 1983), as canlarger randomized clinical trials conducted atseveral sites in different locales. The use ofgeneralizability theory offers a comprehensivevehicle to assess the relative contributions ofseveral factors (Shavelson & Webb, 1991; seeMcCullough, Rachal, & Hoyt, in press, for anexample of applying generalizability theory)

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Question 7: independent,dependent, or moderating variable?In intervention studies, measures of spiritual andreligious factors can serve as independent and/ordependent variables (i.e. as the target of atreatment, or part of the treatment itself), and/ora moderating or mediating categorical variable.For example, an intervention may try to increasea particular spiritual or religious factor, such asfrequency of prayer or meditation (McCullough& Worthington, 1994). By contrast, a spiritualor religious factor can serve as an interventionor part of an intervention designed to changesome health factor, such as depression, hyper-tension, medical care utilization, or all-causemortality (e.g. Benson, 1996). Another approachmight be to classify or categorize patientsaccording to various spiritual or religious factors(e.g. God viewed as loving and forgiving orjudging and punishing) to see if the effects of ahealth intervention are moderated or mediatedby this spiritual or religious factor.

More intervention studies that use spiritualand religious factors as independent, dependent,or moderating variables are needed to overcomesome of the serious limitations of cross-sectionalstudies. Especially valuable are interventionsthat offer glimpses of causal or etiologic factors.For example, Friedman et al. (1986) demon-strated in a randomized clinical trial that reduc-tions in hostile and time-urgent behavior weredirectly associated with reduced coronary fataland non-fatal events. Such changes suggest thathostile and time-urgent behavior and cognitionsmay be implicated in the cause of coronary heartdisease via autonomic nervous system and hypo-thalamic-pituitary-adrenal (HPA) axis pathwaysthat alter cardiovascular and metabolic systems(McEwen, 1998).

Similar studies that focus on spiritual andreligious factors are needed. For example, Tixand Frazier (1998), investigating associations ofreligious and non-religious coping with stressand life satisfaction after kidney transplantsurgery, provide an interesting example of aresearch design that examined possible moderat-ing effects (e.g. type of religious affiliation) andpossible mediating effects (e.g. cognitiverestructuring) of coping on life satisfaction.They found that religious coping was not medi-ated by other factors, such as non-religiouscoping but being Protestant, compared to being

Catholic, moderated the effects of religiouscoping on patient life satisfaction 18 monthsafter surgery.

Note, however, that the above study did notuse a randomized experimental design. While aprospective design using multiple measures on 3occasions over almost 2 years offers decidedbenefits over simple cross-sectional designs, theresults still remain correlational. As such, infer-ences about possible causal mechanisms thatexplain why Protestants using religious copingfared better than Catholics in terms of higher lifesatisfaction remain unclear.

Question 8: how is changemeasured?Since spiritual or religious factors have seldombeen used in well-controlled intervention studies(especially as major outcome measures), theissue of effective assessment remains essentiallyunexamined (Thoresen, 1998). If, for example,the goal of an intervention is to increase selectedspiritual or religious factors and explore how thepattern of change in these factors may alter overtime (e.g. before, during, and after the inter-vention), then measures are essential that can bereliably and validly used on a repeated basis,and that are sensitive enough to detect change.Currently, however, there is a lack of suchmeasures. Also needed are ways to begin toassess spiritual and religious factors that do notexclusively rely on survey or questionnairemethodology. Richards and Folkman (1997), forexample, used quantified interview methods todiscover and then study the role of spiritual andreligious factors, along with positive and neg-ative emotions and coping styles, in caregiverswho had recently experienced the death of theirpartners. Notably, results of questionnaire datain this study would have been seriously mislead-ing without the information provided by theinterviews (see also Idler, 1995). By analyzingquestionnaire data on mood and coping by levelof spiritual experience (assessed from interviewdata), changes over time in mental health statuswere greatly clarified (see Woods & Ironson,1999, this issue, for an example of an interview-based approach).

Studies that collect assessment data period-ically during the interventions process, not sim-ply before and after, are also needed to examineand capture patterns in how individuals experi-

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ence spiritual or religious factors during treat-ment interventions and in documenting theireffects over time. Daily monitoring methodsused in pain research as to mood, self-efficacy,pain level, and coping methods (e.g. Keefe etal., 1997) clarified theoretical issues greatlycompared to only using single pre–post assess-ment strategies. Of the handful of interventionstudies reviewed by Worthington et al. (1996),most only used one measure of religiousness orspirituality (often 1- or 2-item measures) on asingle occasion. A great deal of work remains tobe done to develop ways to assess the clinicalrelevance of spiritual and religious factors withgreater specificity and sensitivity. Withoutadvances in assessment that capture with muchgreater fidelity the breadth and depth of whatpeople experience over time, developing effec-tive interventions that can both provide serviceand clarify theory will remain badly hampered.

Conclusions

Most religious and spiritual interventions cur-rently available or being used have not beencarefully evaluated to demonstrate their efficacyor their effectiveness or clinical validity. Never-theless, there are some interventions for whichsome evidence of efficacy has been demon-strated. Specifically, religiously oriented cogni-tive therapy, meditation, 12-step fellowships,forgiveness therapy, and intercessory prayer allhave some evidence, albeit very modest, sug-gesting their efficacy under specific conditions.Although these studies need further replicationwith better design controls, the findings suggestthat continued development and evaluating ofspiritual/religious interventions would be a veryworthwhile endeavor. A number of strategieshave been mentioned that are needed to improvestudies, thus better ensuring data that will bemore consistent, replicable, and generalizable.

Richards and Potts (1995) and Richards andBergin (1997) have suggested a number ofethical concerns and dangers regarding the useof religious/spiritual interventions, including thedanger of: (1) engaging in dual relationships; (2)usurping religious authority or engaging inquestionable ‘priestcraft’ (i.e. getting paid forreligious services); (3) trivializing the numinousor the sacred; (4) imposing therapists’ religiousor spiritual values on clients; and (5) using

religious/spiritual interventions inappropriatelyin certain work settings (e.g. public education,state or federal government facilities, etc.).

The above examples provide ample rationalefor using care and caution when utilizing inter-ventions. However, these concerns should notbe used to dampen or avoid the much-neededinvestigation and appropriate clinical use ofsuch interventions. Ethical guidelines, standardsof practice, and informed consent are availableand can be further developed and utilized. Weneed to be mindful of both the potential benefitsand possible dangers posed to patients andothers by the use of spiritually and religiouslyrelated interventions.

Given the marked skepticism and strongobjection of some health professionals and otherresearchers to anything spiritual or religious, webelieve that the quality of research and thecaliber of practice in this area must be state-of-the-art (Ellison & Levin, 1998; Larson et al.,1998). We need evidence to determine when,how, and for whom spiritual and religiousinterventions could be included in treatmentregimes with beneficial effects. The markedincrease of interest and concern among researchscholars and clinical practitioners in the role ofspirituality and religion in health will furtherencourage we believe the kind of interventionresearch needed. In the long run, if we conducthigh-quality intervention studies, those we servemay indeed benefit greatly in terms of betteroverall health and quality of life.

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