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Adapted Cognitive-Behavioral Therapy for Religious Individuals with Mental

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DOI: 10.1016/j.ajp.2013.12.011

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 Asian Journal of Psychiatry 9 (2014) 3–12

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Review

Adapted cognitive-behavioral therapy for religious individuals with

mental disorder: A systematic review
Caroline Lim a,*, Kang Sim b, Vidhya Renjan b, Hui Fang Sam c, Soo Li Quah d
a
School of Social Work, University of Southern California, Montgomery Ross Fisher Building, 669 W. 34th Street, Los Angeles, CA 90089, USA
b
Research Division, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore 539747, Singapore
c
Psychological Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
d
Department of Psychology, Faculty of Arts and Social Science, National University of Singapore, Block AS4, #02-07, 9 Arts Link, Singapore 11750, Singapore

A R T I C L E I N F O A B S T R A C T

Article history: Cognitive-behavioral therapy (CBT) is considered an evidence-based psychological intervention for
Received 18 July 2013 various mental disorders. However, mental health clinicians should be cognizant of the population that
Accepted 26 December 2013 was used to validate the intervention and assess its acceptability to a target group that is culturally
different. We systematically reviewed published empirical studies of CBT adapted for religious
Keywords: individuals with mental disorder to determine the extent to which religiously modified CBT can be
Cultural adaptation considered an empirically supported treatment following the criteria delineated by the American
Religion
Psychological Association Task Force on Promotion and Dissemination of Psychological Procedures.
Cognitive-behavioral therapy
Mental disorders
Overall, nine randomized controlled trials and one quasi-experimental study were included that
compared the effectiveness of religiously modified CBT to standard CBT or other treatment modalities for
the treatment of depressive disorders, generalized anxiety disorder, and schizophrenia. The majority of
these studies either found no difference in effectiveness between religiously modified CBT compared to
standard CBT or other treatment modalities, or early effects that were not sustained. Considering the
methodological limitations of the reviewed studies, religiously modified CBT cannot be considered a
well-established psychological intervention for the treatment of the foregoing mental disorders
following the a priori set criteria at this juncture. Nevertheless, melding religious content with CBT may
be an acceptable treatment modality for individuals with strong religious convictions.
! 2014 Elsevier B.V. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3.1. Mood disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3.2. Anxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
3.3. Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1. Introduction

Cognitive-behavioral therapy (CBT) is considered an evidence-

based psychological intervention for various mental illnesses.
Randomized controlled trials show that CBT is a promising
* Corresponding author. Tel.: +1 213 359 4903. adjunctive psychosocial treatment for refractory schizophrenia
E-mail address: carolisl@usc.edu (C. Lim). (Dixon et al., 2010; Tandon et al., 2008; Turkington et al., 2008).

1876-2018/$ – see front matter ! 2014 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ajp.2013.12.011
4 C. Lim et al. / Asian Journal of Psychiatry 9 (2014) 3–12
Findings from meta-analyses indicate strong evidence for CBT in
the treatment of other disorders including depression (Gloaguen
et al., 1998), adult anxiety disorders (Stewart and Chambless,
2009), pediatric posttraumatic stress disorder (Kowalik et al.,
2011), and obsessive-compulsive disorder (Watson and Rees,
2008). However, mental health clinicians should to be cognizant of
the population that was used to validate CBT and assess the
acceptability of this intervention to target groups that are
culturally different.
Culture refers to the way of life for a particular group of people.
The term emphasizes the transmission of traditions, ways of living,
coping behaviors, values, norms, and beliefs (Whaley and Davis,
2007). It considers the influences of age, developmental disabil-
ities, socioeconomic status, sexual orientation, national origin,
gender, and religious orientation (Hays, 2009). Although practi-
tioners and researchers from various disciplines are increasingly
cognizant of the need to adapt evidence-based psychosocial
interventions to be more compatible with the culture of ethnically
diverse populations (Bernal et al., 2009; Castro et al., 2004), less
attention has been directed at adapting psychosocial interventions
to be more congruent with the religious beliefs of individuals with
mental illness (Hodge, 2004).
According to the cultural compatibility hypothesis, evidence-
based psychological treatments are more effective when the
intervention complements the client’s culture (Tharp, 1991).
Adapting interventions to improve congruence between compo-
nents of the intervention and the client’s culture could increase
adherence to the intervention and lead to better outcomes (Fraser
et al., 2009). Cultural adaptation is predicated on two circum-
stances. First, adaptation is warranted when the client does not
find the proposed intervention meaningful or useful, hence
declining to engage in the intervention (Fraser et al., 2009).
Indeed, studies have found an underutilization of mental health
services by Protestants (Larson et al., 1986, 1989) and individuals
with religious affiliations (Borras et al., 2007; Ng et al., 2011). This
discrepancy in service utilization could be attributed to the conflict
in values that mental health interventions encompass, and those
endorsed by individuals with certain religious affiliation (Koenig,
2005; Propst et al., 1992). Second, interventions should be adapted
to be more culturally sensitive when the known risk and protective
factors related to the problem of interest vary according to culture.
Indeed, individuals with mental illness often engage in religious
practices to cope with persistent symptoms and stressful life
events (Mohr et al., 2012; Russinova et al., 2002; Tepper et al.,
2001). Moreover, the use of religious coping methods has been
found to be associated with better mental health outcomes among
individuals with medical and psychiatric illnesses (Koenig, 2007,
2012; Koenig et al., 1992; Tepper et al., 2001). The foregoing
empirical evidences provide the scientific rationale to adapt
existing evidence-based psychological interventions to be more
congruent with the culture of religious individuals with mental
illness in facilitating recovery.
We reviewed empirical studies of CBT adapted for religious
individuals with mental illness and use the criteria proposed by the
Task Force on Promotion and Dissemination of Psychological
Procedures (1995) to determine the extent to which this
intervention, henceforth referred to as religiously modified CBT,
can be considered an empirically supported treatment (see
Table 1). These criteria were developed to facilitate the evaluation
of psychotherapies to determine whether adequate empirical
evidence exist to warrant widespread dissemination in training
and implementation. In addition, we described how CBT was
culturally adapted in some of the reviewed studies using the
framework of the ecological validity model (Bernal et al., 1995).
This model is the first known framework for cultural adaptation of
psychosocial treatments published in the literature and the most
Table 1
Task force’s criteria for empirically validated treatments.
Category I: well-established treatments
1. At least two group design experiments with methodological rigor
and adequate statistical power (n = 30 per group) conducted by
independent investigators demonstrating that the intervention is
either superior to another treatment, and/or the intervention
is equivalent to an established treatment in studies.
OR
2. A sizable number of singe-case design studies that have
demonstrated efficacy by using good experimental design and
comparing the intervention to another treatment.
AND
3. The intervention was delivered according to a treatment manual
or according to clear descriptions of the treatment.
AND
4. The characteristics of the study sample were specified.
Category II: Probably Efficacious Treatments
1. Two experiments must show that the treatment is superior
to waiting-list control group.
OR
2. One or more experiments must meet the criteria for well-established
treatments, but are conducted by the same investigator.
OR
3. At least two good studies demonstrating effectiveness but with a
heterogeneous sample.
OR
4. A small number of single-case design studies demonstrating
efficacy using good experimental design with a comparison group
that comprise another treatment, treatment manuals, and clear
specification of the sample characteristics.
Category III: Experimental Treatments
1. Treatments that have not been established as at least
probably efficacious.
widely referenced (Castro et al., 2004). Although several reviews
have been conducted on religiously modified psychotherapies
(Griner and Smith, 2006; Hodge, 2006; Hook et al., 2010; Paukert
et al., 2011; Post and Wade, 2009), the majority of previous reviews
have tended to focus on psychotherapies in general rather than on
CBT. Moreover, the majority did not use established criteria to
examine the level of empirical support for religiously modified
CBT. Nor has previous reviews use a framework for cultural
adaptation to describe how religiously modified CBT was adapted;
it would seem, therefore, that a description of the adaptation
approach might facilitate the process for mental health practi-
tioners who are considering modifying CBT to be more consonant
with the religious beliefs of their clients.
2. Methods
A search for published empirical studies through June 2013 that
examined the effectiveness of religiously modified CBT was
performed (see Fig. 1). Relevant research articles were searched
in the National Center for Biotechnology Information (NCBI)
PubMed (MEDLINE) and PsycINFO databases using the following
keywords: religion; cognitive-behavioral therapy or modified
cognitive behavioral therapy; cultural adaptation; and mental
illness or mental disorders. Titles and abstracts of the shortlisted
articles were screened. In addition, reference sections of relevant
articles and systematic reviews were examined to extract germane
articles. Articles that met the following criteria were included in
the review: (1) the paper was published in English; (2) participants
included in the studies were diagnosed with an Axis I mental
disorder that includes major depressive disorder, bipolar disorder,
generalized anxiety disorder, obsessive compulsive disorder, panic
disorder, post-traumatic stress disorder, or schizophrenia per the
diagnostic criteria specified in the Diagnostic and Statistical
Manual of Mental Disorders (DSM), the International Classification
[(Fig._1)TD$IG] C. Lim et al. / Asian Journal of Psychiatry 9 (2014) 3–12
Articles identified by searching electronic databases (n=156)
Title and abstracts of shortlisted articles were screened
Full text of potentially relevant articles were retrieved for detailed examination (n=14)
Articles included in review (n=10)
Fig. 1. The flowchart of the review process.
of Diseases (ICD), or a diagnostic manual with similar classification
to either the DSM or ICD; and (3) the paper described a randomized
controlled trial or quasi-experimental study comparing the
effectiveness of religiously modified CBT that was culturally
modified for religious individuals with mental disorder to standard
CBT or other treatment modalities (e.g., medication, psychological
placebo, or another treatment). According to the ecological validity
model, an intervention is considered culturally adapted if one of
the following dimensions of the intervention has been modified to
increase congruence between the client’s cultural experiences
and properties of the treatment: language, persons, metaphors,
content, concepts, goals, methods, and context (Bernal et al., 1995).
Studies that delivered religiously modified CBT to participants
with substance use disorders were excluded from the review, as
were studies that delivered culturally adapted CBT that did not
have one of its treatment dimensions religiously modified to
enhance the ecological validity for religious individuals with
mental disorder. The latter exclusions criterion would comprise of
studies that evaluated interventions such as yoga meditation,
mindfulness-based therapies, spirituality psychological interven-
tions, etc.
3. Results
The search produced nine randomized controlled trials and one
quasi-experimental study that meet the foregoing inclusion
criteria (see Table 2).
3.1. Mood disorders
Pecheur and Edwards (1984) conducted one of the earliest
studies on religiously modified CBT for the treatment of major
depressive disorder. Twenty-one Christian college students
meeting the DSM-III criteria for at least mild depression were
randomly assigned to receive secular CBT (SCBM), religious
modified CBT that incorporated Christian beliefs and practice
(RCBM), or no treatment. Participants in the treatment groups
(n = 14) received individual therapy lasting an hour per session,
semiweekly for four weeks. Severity of the participants’ depression
was measured at baseline, immediately post-treatment and one
5
Articles excluded on the basis of failure to
meet the inclusion criteria (n=152)
Full text of potentially relevant articles
could not be retrieved (n=2)
Articles identified by searching the
reference sections of relevant articles and
systematic reviews (n=12)
month after. Participants who received SCBM and RCBM reported
significantly lower level of depression ratings compared to
participants in the wait-list control group immediately post-
treatment; however, the severity of depression did not differ
significantly between the participants from the treatment groups.
The gains, in terms of improvement in depression score ratings,
achieved by the participants in the treatment groups immediately
post-treatment were maintained at the follow-up assessment.
Employing a more vigorous methodology, Propst et al. (1992)
implemented a randomized controlled trial to compare the efficacy
of standard CBT (NRCT) with religious modified CBT (RCT) for the
treatment of clinical depression in religious individuals. The study
also compared the relative efficacy of these interventions with
pastoral counseling (PCT), which did not have the active
ingredients of CBT, and a waiting-list control (WLC) condition.
Sixty-five participants were randomly assigned to one of the
following treatment conditions: NRCT delivered by religious
therapist or non-religious therapist, RCT delivered by nonreligious
therapist or religious therapist, PCT, and WLC. Six participants
dropped out before completing the study protocol. The remaining
59 participants received between 18 and 20 one-hour sessions of
intervention over three months. The participants’ depression
rating scores, social functioning, and severity of general psycho-
pathology were assessed prior to treatment, at treatment
termination, and three and 24 months post treatment. The
researchers found that at treatment termination, participants
who received RCT (n = 19) fared significantly better than partici-
pants in WLC (n = 11): participants in the former treatment
condition achieved greater reductions in rating scores of depres-
sion and general symptomatology, and greater improvement in
social adjustment. Although participants who received NRCT
(n = 19) and PCT (n = 10) also fare better than the participants
within the WLC group in the foregoing outcomes at treatment
termination, the gains were not statistically significant. Using the
reliable change index to determine if the improvements made are
clinically significant, only participants in the RCT and PCT group
were found to have made clinically significant improvement. These
findings suggest that modifying CBT to complement the worldview
of religious individuals with mental illness may enhance the
effectiveness of standard CBT.

Table 2
Overview of studies included in the review.
Study Sample Design
Mood disorders
Pecheur and 21 Christian college students Random assignment to treatment
Edwards (1984) meeting the DSM-III criteria for conditions.
at least mild depression Severity of depression was
measured at baseline, immediately
post-treatment, and one month
after treatment termination.
Propst et al. (1992) 59 religious individuals with Random assignment to treatment
clinical depression conditions.
Depression rating scores, social
functioning, and severity of general
psychopathology were assessed at
baseline, at treatment termination,
and at three- and 24-months
follow-up.
Treatment conditions
1. SCBM: secular CBT (n = 7)
2. RCBM: modified CBT that
incorporate Christian beliefs and
practice (n = 7)
3. No treatment (n = 7)
SCBM and RCBM delivered
semiweekly for four weeks.
1. NRCT-NT: Standard CBT with
nonreligious therapist (n = 10)
2. NRCT-RT: Standard CBT with
religious therapist (n = 9)
3. RCT-NT: Religious modified CBT
with nonreligious therapist (n = 9)
4. RCT-RT: Religious modified CBT
with religious therapist (n = 10)
5. PCT: pastoral counseling (n = 10)
WLC: wait-list control group
(n = 11)
18–20 one-hour sessions of the
foregoing treatments were
delivered over three months
6
Outcome Comments
Immediately post-treatment: Religiously modified CBT and
standard CBT were found to be
! SCBM > No treatment equally effective compared to no
treatment.
! RCBM > No treatment
! SCBM = RCBM
One month after treatment termination:
! Gains maintained
! SCBM = RCBM
Participants in the three treatment conditions Cautious support for the superiority
were substantially better immediately post- of religiously modified CBT
treatment than at pretest. compared to standard CBT; CBT
Severity of depression immediately post modifications that include religious
treatment measured with BDI: elements may be helpful.
C. Lim et al. / Asian Journal of Psychiatry 9 (2014) 3–12
! RCT < WLC
! PCT and NRCT < WLCa
! RCT-NT < WLC and NRCT-NT
! NRCT-RT < WLC
! RCT-NT < NRCT-NT
! RCT-NT = RCT-RT
Severity of depression immediately post
treatment measured with HRSD:
! RCT and PCT < WLCa
! RCT-NT < WLC
Social functioning immediately post treatment
! RCT > WLC
! RCT-NT > WLC, PCT, and NRTC-NT
! RCT-RT > WLC
General psychopathology immediately post
treatment:
! RCT < WLC
! RCT-NT <WLC
Three- and 24-months follow-up assessments
of depression scores:
! NRCT = RCT = PCT
! RCT-NT < RCT-RT
! NRCT-RT < RCT-RT
! Note: participants from WLC were not
included in the analyses as they received
treatment at the end of the wait-list period
Hawkins 29 Christian inpatients with
et al. (1999) depression
Azhar and Varma 30 ethnic Malays seeking
(1995a) treatment for major depression
associated with bereavement
Azhar and Varma 64 ethnic Malays seeking
(1995b) treatment for dysthymic
disorder
Razali et al. 100 Malay participants with
(1998) major depression
Anxiety disorders
Azhar and Varma (1994) 62 Muslim patients with
general anxiety disorder (GAD)
Quasi-experimental design: the
inpatients could choose to
participate in either treatment
conditions.
Severity of depression was
measured at baseline and upon
discharge from the inpatient
treatment program.
Random assignment to treatment
conditions.
Severity of depression measured at
baseline, and at one-, three-, and
six-months follow-up.
Random assignment to the
treatment conditions.
Severity of affective symptoms was
measured at baseline, and at one-,
three-, and six- follow-up.
Random assignment to the
treatment conditions.
Severity of affective symptoms was
measured at baseline, and at one-,
three-, and six-months follow-up.
Random assignment to the
treatment conditions.
Severity of anxiety symptoms was
measured at baseline, and at one-,
three-, and six-months follow-up.
1. CCBT: Christian CBT group
(n = 18)
2. CBT: standard CBT group (n = 11)
All participants received a
combination of individual and
group therapy for the duration of
their inpatient treatment.
The average length of stay was 7.5
days (SD = 2.9) and 5.4 (SD = 3.1) for
participants who chose the CCBT
and CBT groups respectively.
1. Control group: antidepressant
and weekly supportive therapy
(n = 15)
2. Study group: antidepressant,
weekly supportive therapy, and
weekly religiously modified
psychotherapy that employed the
cognitive behavioral approach
(n = 15)
All participants received between
12 and 16 session of
psychotherapy.
1. Control group: anti-depressants
and weekly psychotherapy only
(n = 32).
2. Experimental group: anti-
depressants, weekly
psychotherapy, and religiously
modified CBT (n = 32).
The foregoing interventions were
delivered weekly for 12–16 weeks.
1. Standard treatment:
antidepressants, supportive
psychotherapy (n = 48).
2. Experimental group:
antidepressants, supportive
psychotherapy, and religious-
cultural psychotherapy (n = 52)
Information on the frequency and
the duration of the foregoing
interventions was not provided.
1. Control group: anti-depressants
and weekly psychotherapy only
(n = 31).
2. Experimental group: anti-
depressants, weekly
psychotherapy, and religiously
modified CBT (n = 31).
All patients were given 12–16
sessions of weekly therapy that
lasted for about 45 minutes per
sessions.
Severity of depression at baseline:
! CCBT < CBT (difference was not significant).
Severity of depression at treatment
termination:
! CCBT < CBTa
Severity of depression at one-month, three-
months, and six-months follow-up:
Study group < Control group
One-month and three-months follow-up:
! Experimental group < Control group
Six-months follow-up:
! Experimental group = Control group
One-month and three-months follow-up:
! Experimental group < Control group
Six-months follow-up:
! Experimental group = Control group
One-month and three months follow-up:
! Experimental group < Control group
Six-months follow-up:
! Experimental group = Control group
Religiously modified CBT and
standard CBT were found to be
equally effective.
Addition of religiously modified
CBT to standard treatment was
more effective than standard
treatment alone.
C. Lim et al. / Asian Journal of Psychiatry 9 (2014) 3–12
Addition of religiously modified
CBT was associated with faster
remission of symptoms compared
to standard treatment; however,
gains were not sustained.
Addition of religiously modified
CBT was associated with faster
remission of symptoms compared
to standard treatment; however,
gains were not sustained.
Addition of religiously modified
CBT was associated with faster
remission of symptoms compared
to standard treatment; however,
gains were not sustained.
7
 8
Table 2 (Continued )

Study Sample Design Treatment conditions Outcome Comments

Razali et al. (1998) 103 Malay participants with
GAD
Random assignment to the
treatment conditions.
Severity of anxiety symptoms was
measured at baseline, and at one-,
three-, and six-months post
treatment.
1. Standard treatment:
benzodiapines and supportive
psychotherapy (n = 54).
2. Experimental treatment:
benzodiapines, supportive
psychotherapy, and religious-
cultural psychotherapy (n = 49).
Information on the frequency and
the duration of the foregoing
interventions was not provided.
One-month and three-months post treatment:
! Experimental group < Control group
Six-months post treatment:
! Experimental group = Control group
Addition of religiously modified
CBT was associated with faster
remission of symptoms compared
to standard treatment; however,
gains were not sustained

Razali et al. (2002) 165 Malay patients with GAD; Random assignment to the 1. Standard treatment: One-month and three-months post treatment: Addition of religiously modified
religious and non-religious treatment conditions. benzodiapines, supportive CBT was associated with faster
patients psychotherapy, and relaxation remission of symptoms compared
exercises (n = 78). to standard treatment; however,
Severity of anxiety symptoms was 2. Experimental group: ! Experimental group < Control group gains were not sustained

C. Lim et al. / Asian Journal of Psychiatry 9 (2014) 3–12

measured at baseline, and at one-,
three-, and six-months post
treatment.
benzodiapines, supportive
psychotherapy, and religious-
cultural psychotherapy (n = 87).
Information on the frequency and Six-months post treatment:
the duration of the foregoing
interventions was not provided.
! Experimental group = Control group

Zhang et al. (2002) 143 Chinese patients with GAD Random assignment to the
treatment conditions.
Symptom severity was measured at
baseline, and at one- and six-
months post treatment.
1. CTCP: Chinese Taoist cognitive Severity of anxiety symptoms at one-month Religiously modified CBT more
psychotherapy (n = 46) follow-up: effective than medication alone
2. BDZ: Benzodiazepine treatment ! BDZ and Combined < CTCP
and short therapy (n = 48)
3. Combined: CTCP and BDZ ! BDZ = CTCP
treatment (n = 49)
Participants in CTCP or the Severity of anxiety symptoms six-months
combined treatment group follow-up:
received weekly one-hour session ! CTCP and Combined < BDZ
for one month followed by ! CTCP = Combined
biweekly sessions for five months;
participants in BDZ received
therapy session that lasted no more
than 10 min.

Schizophrenia
Wahass and Kent (1997) Six patients diagnosed with
schizophrenia according to the
ICD-10 criteria
Random assignment to the
treatment conditions.
Severity of hallucination was
measured at baseline, during the
study, and three-months post
treatment for patients in the
treatment group, but only at
baseline and three-months post
treatment for patients in the
comparison group.
1. Comparison group: At three-months post intervention: Treatment Religiously modified CBT may be
antipsychotics only (n = 3) group < Comparison group effective; however, conclusion is
2. Treatment group: antipsychotics limited by the small sample size
and psychotherapy that
incorporated religious teachings
(n = 3)
Patients in the treatment group
received three sessions of one-hour
long psychological interventions
per week for a total of 25 sessions.

BDI = Becks Depression Inventory, HRSD = Hamilton Rating Scale for Depression.
a
Trend towards significance.
 C. Lim et al. / Asian Journal of Psychiatry 9 (2014) 3–12
The cognitive-behavioral psychotherapy model works on the
assumption that the modification of negative cognitions is
fundamental to the treatment of a psychological disorder; thus,
individuals undergoing CBT learn to understand the influence of
cognitions on emotions and behaviors, monitor their cognitions,
identify irrational thoughts, and restructure these irrational
thoughts. Propst et al. (1992) adapted the standard CBT for
religious individuals with depression by employing Christian
doctrines to counter irrational thoughts. A treatment manual was
developed that describes techniques using biblical principles to
restructure negative thoughts into either positive or neutral
thoughts (Propst, 1988). In essence, Propst et al. (1992) improved
the ecological validity of the standard intervention by modifying
the treatment method used for cognitive restructuring. The
incorporation of religious principles within the cognitive restruc-
turing method also enabled the therapists to employ treatment
concepts and contents that were more congruent with the belief
systems of the participants. This adaptation could have enhanced
treatment effectiveness through better retention and adherence to
the treatment procedures as is evident from the low dropout rate
in the study. Indeed, individuals who withdrew from the
intervention described themselves as being less religious com-
pared to the participants who completed the study. Although it
was not explicitly stated nor measured as an outcome, Propst
(1988) alluded in the treatment manual that one of the goals of this
adapted intervention included spiritual well-being; hence, the
congruence between the treatment goals of the therapists and the
clients might have contributed to the study’s high retention rate. In
the same study, Propst et al. (1992) further endeavored to improve
the ecological validity of the intervention by using religious
therapists to deliver the various treatment conditions, but yielded
no outcome differences when compared with the nonreligious
therapists. In fact, the greatest effect of RCT was achieved when
nonreligious therapists delivered the intervention.
The use of religiously modified CBT in group therapy for
depression has been examined. Hawkins et al. (1999) compared
the effectiveness of Christian CBT (CCBT) with standard non-
religious CBT in treating a sample of Christian inpatients who
fulfilled the DSM-IV criteria for depression (n = 29). The partici-
pants were not randomly assigned: 18 participants chose to
participate in the Christian CBT group and 11 chose the standard
CBT group. All of the participants received a combination of group
and individual therapy. The adaptation of the CBT model proposed
by Hawkins et al. (1999) appears to be similar to the adaptation by
Propst et al. (1992). The Christian CBT intervention presented
participants with biblical teachings of topics covered during the
individual and group sessions; however, the researchers did not
explicitly state if the use of Christian concepts were intended to
counter the participants’ irrational thoughts. Compared to the
earlier study, Hawkins et al. (1999) incorporated prayer as an
additional technique and included pastors and Christian therapists
to deliver the interventions. In essence, the researchers modified
several dimensions of the intervention to enhance its ecological
validity: characteristics of the therapists, goals of the intervention,
and methods for treatment. Although participants in both
treatment groups reported a reduction in severity of depression
ratings from baseline upon their discharge from inpatient
treatment, the post-treatment depression ratings did not differ
significantly between the treatment conditions. However, the
researchers noted a trend towards a significant positive difference
that favored participants who received CCBT and commented that
a more favorable outcome might have been detected with a larger
sample size.
Although the studies reviewed hitherto have only examined the
effectiveness of religiously modified CBT in treating depression
amongst Christians, the adaptation of CBT for other religious
9
groups have also been undertaken and evaluated. Azhar and Varma
(1995a) randomly assigned 30 ethnic Malays with strong religious
and cultural beliefs seeking treatment for major depressive
disorder associated with bereavement, where the diagnosis was
made according to the DMS-III-R criteria, to either the experimen-
tal (n = 15) or the control group (n = 15). Participants in both
groups received anti-depressants and 12–16 sessions of weekly
psychotherapy. However, participants in the experimental group
concurrently received psychotherapy drawing on the tenets of CBT
that incorporated teachings from the Holy Koran – therefore, the
ecological validity of the intervention was enhanced by modifying
the treatment method used for cognitive restructuring. A
psychiatrist blinded to the assignment assessed the severity of
the participants’ affective symptoms at several predetermined
points. The assessments revealed that participants in the
experimental group achieved faster remission than participants
in the control group as evidenced by significantly lower depression
scores at the first- and third-month follow-up assessment.
Evaluation completed at the sixth-month follow-up revealed that
the gains made by the participants in the experimental group were
sustained. The same investigators replicated the experiment with a
larger sample size (Azhar and Varma, 1995b); sixty-four ethnic
Malays seeking treatment for dysthymic disorder were randomly
assigned to either the experimental group (n = 32) or the control
group (n = 32). Likewise, the findings indicate that participants in
the experiment group achieved significantly faster symptomatic
remission than participants in the control group; however, no
significant difference in depression scores was detected between
the groups at six-months follow-up.
3.2. Anxiety disorders
Azhar et al. (1994) employed the same research design as the
foregoing studies (Azhar and Varma, 1995a, 1995b) with 62
Muslim patients diagnosed with general anxiety disorder (GAD) to
test the effectiveness of a CBT that incorporated the teachings from
the Holy Koran. The researchers noted similar findings in that
participants from the experimental group (n = 31) achieved
significantly faster remission of anxiety symptoms; however,
participants from the comparison group (n = 31) caught up by the
sixth month follow-up assessment.
Razali et al. (1998) used a similar research methodology with a
larger sample of 203 participants. Participants with GAD (n = 103)
or major depression (n = 100) were randomly assigned to either
the experimental or the control group. Similar rating scales were
used but outcomes were measured at shorter intervals. Patients
from the study group improved significantly faster than the
control group as improvements were noted by the fourth and 12th
weeks; however, the difference was negligible by the end of
treatment.
Razali et al. (2002) evaluated the effectiveness of religious-
cultural psychotherapy in the treatment of GAD amongst religious
and non-religious Malay patients. Research participants were
diagnosed with GAD based on the DSM-III-R criteria. The study
recruited 165 participants with 85 participants assessed to be
religious and the remaining participants assessed to be non-
religious. The participants were randomly assigned into the study
(n = 87) or the alternative treatment group (n = 78). Participants in
both groups received standard treatment for GAD that included
benzodiapines and supportive psychotherapy. However, partici-
pants in the study group also received religious-cultural
psychotherapy (RCP) over an unspecified period. Findings from
this study are consistent with that found in the study by Azhar
et al., 1994. Religious patients in the study group achieved faster
remission of anxiety symptoms than those in the comparison
group: a significant difference in the severity of anxiety symptoms
10 C. Lim et al. / Asian Journal of Psychiatry 9 (2014) 3–12
between the two groups of patients was detected one month into
the treatment. By the 26th week, religious patients in the
comparison group fared as well as religious patients in the study
group, suggesting no difference in effectiveness of religiously
adapted CBT compared with supportive psychotherapy in the
treatment of GAD. The researchers commented that the initial
efficacy of the adapted intervention might be partly attributed to
the patients’ strong commitment to their religion. Indeed, the
adaptation did not have a significant effect on non-religious
patients, as the researchers did not detect a difference in the
severity of anxiety symptoms between the study and comparison
group during and post treatment amongst the non-religious
patients.
The abovementioned studies attempted to demonstrate the
initial effectiveness of religiously oriented cognitive therapy for
Muslim patients with GAD in terms of faster remission of
symptoms (Azhar and Varma, 1994; Razali et al., 1998, 2002).
The researchers modified certain dimensions of the respective
interventions to make them more compatible with the
participants’ culture. Although the interventions employed
techniques similar to the traditional cognitive model developed
by Beck and colleagues, participants were taught to recognize
their underlying negative cognitions and substitute irrational
thoughts using religious-oriented interpretations guided by
teachings of the Holy Koran and the Hadith. Moreover, the
therapists who delivered the interventions had fundamental
knowledge of Islamic teachings. Therefore, the ecological
validity of the interventions was enhanced by improving the
cultural congruence between the therapists and the patients, by
employing culturally accepted treatment methods through the
use of the Holy Koran and Hadith, and by tailoring the concepts
and content of the intervention to be more consonant with the
participants’ religious beliefs.
Pointing out the influence of Confucianism and Taoism in the
daily lives of Chinese people, Zhang et al. (2002) incorporated
Confucian and Taoist values into cognitive psychotherapy for the
treatment of anxiety disorder amongst Chinese patient. They
randomly assigned 143 patients who met the Chinese Classifi-
cation of Mental Disorders (second revision) criteria for GAD to
one of the following treatment groups: Chinese Taoist cognitive
psychotherapy (CTCP), benzodiazepine treatment only (BDZ),
and combined CTCP and BDZ treatment. Patients assigned to
either CTCP (n = 46) or combined treatment group (n = 49)
received weekly hour-long session of therapy for one month
followed by biweekly session for five months. Patients in the
BDZ group (n = 48) received equal number of therapy sessions,
but each session lasted no more than 10 min. The patients’
symptoms severity, coping style, and personality were assessed
before the initiation of treatment and one and six months into
the treatment. With regard to symptoms severity, patients who
had been on medication achieved faster remission as evidenced
by report of less severe symptoms after one month of treatment;
however, patients who had received only medication without
CTCP deteriorated subsequently. In contrast, patients who
received CTCP made steady recovery and were assessed to have
significantly less severe symptoms after six months of treatment
compared to patients who received benzodiazepine treatment
only. Moreover, patients who had been receiving CTCP were
found to have adopted more healthy coping methods compared
to patients from the BDZ only treatment group after six months.
It is also noteworthy that the CTCP group had the lowest
dropout rate (n = 4, 8.2%) amongst the three treatment groups.
Although the researchers did not include standard cognitive
psychotherapy as a comparison treatment, findings from this
study indicate that religiously adapted cognitive psychotherapy
is an effective treatment for GAD.
3.3. Schizophrenia
In a sample of patients with refractory schizophrenia, Wahass
and Kent (1997) investigated the efficacy of religiously modified
psychological intervention in alleviating persistent auditory
hallucination. Six patients diagnosed with refractory schizophre-
nia in accordance to the ICD-10 criteria participated in the study.
They had been receiving antipsychotic treatment for at least four
years prior to being enrolled in the study and were maintained on
the treatment during the study. The patients were randomly
assigned to either the treatment or comparison group. Over nine
weeks, the patients in the treatment group received a maximum of
25 one-hour long sessions of psychological intervention aimed at
equipping the patients with various cognitive-behavioral methods
to cope with persistent symptoms. The therapist had adapted the
coping techniques to be more appropriate for Islamic patients:
several secular coping strategies were replaced with religious-
influenced methods such as using prayers and reading the Quran to
gain control over the hallucinations, using Islamic doctrines to
challenges beliefs surrounding the content of the voices, and
listening to recitation of the Quran to reduce the distress
associated with the hallucination. The therapist administering
the intervention had attended courses on cognitive-behavioral
techniques, and delivered the interventions according to published
guidelines. At three months post intervention, the researchers
noted that two of the three patients from the treatment group
reported improvement in several characteristics of the hallucina-
tions that includes frequency, loudness, clarity, and distress level;
however, the patients from the comparison group maintained
status quo. The researchers concluded that modifying psychologi-
cal interventions to improve cultural congruence could be
beneficial.
4. Discussion
The present paper reviewed studies of religiously modified CBT
and several conclusions can be drawn. Overall, the result of the
review indicates that religiously modified CBT cannot be consid-
ered a well-established psychological intervention for the treat-
ment of mental disorders – depressive disorders, generalized
anxiety disorder, and schizophrenia – in accordance to the criteria
specified by the Task Force (1995). The reviewed studies have
several notable methodological limitations that merit cautious
interpretation of the results as scientific evidence that religiously
modified CBT is superior to standard CBT and other treatment
modalities. First, the comparator of standard CBT was not always
present, but instead included other forms of treatment modalities
such as supportive psychotherapy (Azhar et al., 1994; Azhar and
Varma, 1995a, 1995b; Razali et al., 1998, 2002) or medication only
(Zhang et al., 2002; Wahass and Kent, 1997), thus disallowing
determination of the specific effectiveness of religiously modified
elements in CBT. Second, religiously modified CBT was combined
with pharmacotherapy in most of the reviewed studies, precluding
better appreciation of the effects of the psychological intervention
alone. Third, the wide variations in the implementation of
religiously modified CBT – with variable number, frequency, and
duration of sessions – along with the lack of a treatment manual in
the majority of the reviewed studies mean that we cannot be
certain that the intervention was delivered in accordance with the
tenets of CBT. Fourth, some studies were insufficiently powered
and might have incorrectly concluded that religiously modified
CBT and other treatments are equally effective in alleviating
symptom (e.g., Hawkins et al., 1999; Pecheur and Edwards, 1984).
Fifth, although studies with adequate statistical power found
religiously modified CBT to be as effective as standard CBT (e.g.,
Propst et al., 1992) or superior to other treatment modalities, the
 C. Lim et al. / Asian Journal of Psychiatry 9 (2014) 3–12
findings have not been replicated by different investigators (e.g.,
Azhar et al., 1994; Azhar and Varma, 1995a, 1995b; Razali et al.,
1998, 2002). Sixth, the analyses in the majority of the reviewed
studies have concentrated on examining bivariate relations
without controlling for participants’ demographic and clinical
characteristics such as age, gender, marital status, and duration of
illness, which may exaggerate or create spurious associations
between the treatments and the investigated outcomes. Consider-
ing these methodological limitations, religiously modified CBT can
at best be considered a probably efficacious treatment for
depressive disorders and generalized anxiety disorders, and an
experimental treatment for schizophrenia.
Notwithstanding the foregoing limitations, it is noteworthy
that none of the studies reviewed found religiously modified CBT to
be inferior to a control condition or other treatments. For example,
CBT that was modified to incorporated religious content yielded
better outcomes and clinically significant improvement post
treatment in participants with clinical depression compared to a
control condition (Propst et al., 1992); psychotherapy that
incorporated religious and cultural content was associated with
remission of anxiety and depressive symptoms as standard
psychotherapy (Azhar et al., 1994; Azhar and Varma, 1995a,
1995b; Razali et al., 1998, 2002); and cognitive psychotherapy that
considers Confucius and Taoist values was as effective as
benzodiazepine in treating GAD (Zhang et al., 2002). These results
suggest that melding religious content with CBT could be an
acceptable treatment modality for use with religious individuals
with mental illness. This finding is consistent with several research
reviews and meta-analyses on culturally adapted mental health
interventions (Griner and Smith, 2006; Hodge, 2006; Post and
Wade, 2009).
Respecting the adaptation of CBT to enhance the ecological
validity of the intervention for religious individuals with mental
illness, common elements of the intervention that have been
modified include methods, concepts, and contents by drawing on
religious scriptures and incorporating religious tenets for cognitive
restructuring. Religiously adapted CBT was well received as
evidenced by the low dropout rates reported in some of the
studies (e.g., Propst et al., 1992; Zhang et al., 2002). When therapist
effects were investigated to determine whether participants
yielded better outcomes when religious therapists delivered the
interventions, an outcome differential that favored nonreligious
therapists was noted, suggesting that the role of religious
similarities between the client and the therapist in shaping the
therapeutic relationship might be minimal.
5. Conclusions
A few points can be made from this review. First, the majority
of studies concentrated on evaluating the effects of religiously
oriented CBT in depressive disorder and anxiety disorders and
either showed no difference in effectiveness compared with
standard CBT or another treatment, or early effects which were
not sustained. Second, the overall evidence base is small with
limited number of studies of the different conditions; nonethe-
less, there is some data to suggest that incorporating religious
dimension in therapy may be more important for persons with a
religious bent. Third, the scarcity of studies circumscribes the
conclusions that can be drawn in regard to the effectiveness of
religiously modified CBT as a treatment modality for severe
mental illness such as schizophrenia. Additionally, studies have
hitherto been concerned with adaptation of CBT for participants
who identified as Christians, Muslim, and Buddhist; little is,
however, known about the effectiveness of religiously modified
CBT among individuals who report being affiliated with other
religious traditions.
11
What are the clinical and research implications? First, mental
health professionals should consider incorporating in their clinical
assessments patients’ religious identification and the use of
religious coping techniques, if any, to manage stressful life events
(Koenig, 2013). Studies have found that individuals with severe
mental illnesses such as schizophrenia and affective disorders
often use religious beliefs and behavior to cope with persistent
symptoms and stressful life events (Russinova et al., 2002; Tepper
et al., 2001).
Second, having a deeper understanding of the use of religious
coping in patients will enable mental health professionals to
deliver interventions that are more culturally sensitive. Part of
patient-centered care involves delivering treatments that respect
the wants, needs, and preferences of the patients, which can foster
better rapport and facilitate the establishment of firmer collabo-
rative relationship with patients with strong religious convic-
tions. There is increasing emphasis on the significance of
evaluating religious background in psychiatry as evidenced by
the example of the American College of Graduate Medical
Education requiring the Residency Training Program in Psychiatry
to provide training on religious or spiritual factors that influence
psychological development (Accreditation Council on Graduate
Medical Education, 2000). Therefore, mental health professionals
are encouraged to consider the contribution of religion to the
recovery of their patients and present their patients with the
option of incorporating religious tenets within therapeutic
modalities and the option of declining this integration. Koenig
(2012) made several noteworthy recommendations for addres-
sing and integrating religious issues in clinical care.
Third, we recognize that mental health professionals who
identify themselves as being less religious or spiritual might feel
uncomfortable discussing religious matters with their clients or
might want to deemphasize the importance of religiosity in their
clients’ recovery (Hodge, 2011). As the societies that we live in
become increasingly ethnically diverse and multi-religious,
understanding the various religions and adapting interventions
for more religious clients might prove daunting for some mental
health professionals. Therefore, it is crucial to understand when
and for whom religion could be incorporated to enhance the
effectiveness of psychotherapy (Paukert et al., 2011). Hodge (2011)
recommends incorporating religious or spiritual interventions in
clinical practice based on four factors: client preference, evaluation
of relevant research, clinical expertise, and cultural competency.
These guidelines will assist clinicians in using these interventions
in a professional and ethical manner that will foster client welfare.
Fourth, with regard to implications for research, future studies
may wish to investigate patients with different conditions using
standard comparisons to allow better understanding of the
effective elements of psychotherapeutic treatments as well as
facilitate better comparability between studies of religiously
modified treatments; indeed, a randomized controlled trial
comparing the effectiveness of standard CBT with religiously
modifiedCBTforthetreatmentofmajordepressionin chronicallyill
patients is underway (Koenig, 2012). Studies with larger sample
size and longer duration of follow up are needed to appreciate the
presence and sustainability of positive effects or otherwise of these
treatments. Incorporating different outcome measures such as
functional assessments will also allow evaluation of the practical
impact of these religiously adapted psychotherapies in the lives of
patients with mental illness. Further investigations are also needed
to ascertain the differential effects of using religious and non-
religious therapists in delivering religiously modified CBT. Lastly,
qualitative interviews with clients who report affiliations with
religious traditions that have not been investigated will help
determine what elements and dimensions of CBT should be
modified to enhance its ecological validity.
12 C. Lim et al. / Asian Journal of Psychiatry 9 (2014) 3–12
Role of funding source
This research was not supported by any grants.
Conflict of interest
There is no conflict of interest to disclose.
Contributors
Caroline Lim was responsible for the conception and design of
the manuscript, reviewed the literature, selected the appropriate
studies to be included, and wrote the majority of the manuscript.
Kang Sim co-authored the paper, reviewed the drafts of the
manuscript, gave critical comments and suggestions, and approved
the version of the manuscript for publication. Vidhya Renjan, Hui
Fang Sam, and Soo Li Quah reviewed the selected studies and were
responsible for drafting and revising parts of the manuscript.
Acknowledgements
The authors wish to thank A/Prof. Chong Siow Ann and Dr.
Mythily Subramaniam for their support, A/Prof. Maria Aranda for
her guidance, and A/Prof. Ann Marie Yamada and A/Prof. Wong
Mee Lian for their invaluable comments on the manuscript.
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