statistical essay

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Research on Religion-Accommodative Counseling:

Review and Meta-Analysis

Michael E. McCullough

National Institute for Healthcare Research

The present meta-analysis examined data from 5 studies (N = 111) that compared the efficacy

of standard approaches to counseling for depression with religion-accommodative approaches.

There was no evidence that the religion-accommodative approaches were more or

less efficacious than the standard approaches. Findings suggest that the choice to use religious

approaches with religious clients is probably more a matter of client preference than a matter

of differential efficacy. However, additional research is needed to examine whether religionaccommodative

approaches yield differential treatment satisfaction or differential improvements

in spiritual well-being or facilitate relapse prevention. Given the importance of religion

to many potential consumers of psychological services, counseling psychologists should

devote greater attention to religion-accommodative counseling in future studies.

The United States is a highly religious country; 92% of its

population are affiliated with a religion (Kosmin & Lachman,

1993). According to a 1995 survey, 96% of Americans

believe in God or a universal spirit, 42% indicate that they

attend a religious worship service weekly or almost weekly,

67% indicate that they are members of a church or synagogue,

and 60% indicate that religion is “important” or

“very important” in their lives (Gallup, 1995).

In addition, many scholars acknowledge that certain

forms of religious involvement are associated with better

functioning on a variety of measures of mental health.

Reviews of this research (e.g., Bergin, 1991; Bergin, Masters,

& Richards, 1987; Larson et al., 1992; Pargament,

1997; Schumaker, 1992; Worthington, Kurusu, McCullough,

& Sandage, 1996) suggested that several forms of

religious involvement (including intrinsic religious motivation,

attendance at religious worship, receiving coping

support from one’s religious faith or religious congregation,

and positive religious attributions for life events) are positively

associated with a variety of measures of mental health.

For example, various measures of religious involvement

appear to be related to lower degrees of depressive symptoms

in adults (Bienenfeld, Koenig, Larson, & Sherrill,

1997; Ellison, 1995; Kendler, Gardner, & Prescott, 1997)

and children (Miller, Warner, Wickramaratne & Weissman,

1997) and less suicide (e.g., Comstock & Partridge, 1972;

Kark et al., 1996; Wandrei, 1985).

Koenig, George, and Peterson (1998) reported that depressed

people scoring high on measures of intrinsic religiousness

were significantly more likely to experience a

remission of depression during nearly a 1-year follow-up

than were depressed people with lower intrinsic religiousness,

even after controlling for 30 potential demographic,

psychosocial, and medical confounds. Other studies have

Correspondence concerning this article should be addressed to

Michael E. McCullough, National Institute for Healthcare Research,

6110 Executive Boulevard, Suite 908, Rockville, Maryland

20852. Electronic mail may be sent to [email protected]

shown that religious involvement, as gauged through singleitem

measures of frequency of religious worship and private

prayer as well as more complex measures of religious

coping, is related to positive psychological outcomes after

major life events (e.g., Pargament et al., 1990; Pargament et

al., 1994; Pargament, Smith, & Brant, 1995). This is the case

even though several patterns of religious belief and religious

coping (e.g., the belief that one’s misfortunes are a punishment

from God) are associated with greater psychological

distress (Pargament, 1997).

Religion in Counseling and Psychotherapy

Some scholars (e.g., Bergin, 1991; Payne, Bergin, &

Loftus, 1992; Richards & Bergin, 1997; Shafranske, 1996;

Worthington et al., 1996) posited that considering clients’

religiousness while designing treatment plans might have an

important effect on the efficacy of treatment. Surveys of

psychiatrists (Neeleman & King, 1993), psychologists (Bergin

& Jensen, 1988; Shafranske & Malony, 1990), and

mental health counselors (Kelly, 1995) also indicate that

many mental health professionals believe that religious and

spiritual values can and should be thoughtfully addressed in

the course of mental health treatment. Moreover, a variety of

analogue and clinical studies (e.g., Houts & Graham, 1986;

T. A. Kelly & Strupp, 1992; Lewis & Lewis, 1985;

McCullough & Worthington, 1995; McCullough, Worthington,

Maxey, & Rachal, 1997; Morrow, Worthington, &

McCullough, 1993) indicate that clients’ religious beliefs

can influence both (a) the conclusions of clinicians’ structured

psychological assessments and (b) the process of

psychotherapy (cf. Luborsky et al., 1980).

Evidence From Comparative Efficacy Studies

Given the existing research on religion and mental health,

an important question for counseling psychologists is whether

supporting clients’ religious beliefs and values in a structured

treatment package yield clinical benefits that are equal

to or greater than standard methods of psychological prac-



tice. Several empirical studies have addressed this issue.

Although the findings of studies that have examined such

questions have been reviewed in narrative fashion elsewhere

(e.g., W. B. Johnson, 1993; Matthews et al., 1998; Worthington

et al., 1996), no researchers have used meta-analytic

methods to estimate quantitatively the differential efficacy of

such treatments. Meta-analytic reviews that compare religious

approaches to counseling with standard approaches to

counseling are one of three meta-analytic strategies that can

be used to examine whether a given therapeutic approach

has therapeutic efficacy (Wampold, 1997).

In the present article, I review the existing research on

such religious approaches to counseling using quantitative

methods of research synthesis (e.g., Cooper & Hedges,

1994; Hunter & Schmidt, 1990) to estimate the differential

efficacy of religious approaches in comparison to standard

forms of counseling for depressed religious clients.


Literature Search

The PsycLIT, PsycINFO, Medline, ERIC, and Dissertation

Abstracts electronic databases were searched through August 1998

for published and unpublished studies that examined the differential

efficacy of a religion-accommodative approach to counseling in

comparison to a standard approach to counseling. The reference

sections of relevant articles were searched for other studies that

would be relevant to this review. This search process continued

until no new studies were revealed. In addition, several experts in

the field of religion and mental health were contacted to identify

unpublished studies.

Studies had to meet four criteria to be included in the metaanalytic

sample: They had to (a) compare a religion-accommodative

approach to counseling to a standard approach to counseling;

(b) randomly assign patients to treatments; (c) involve patients who

were suffering from a specific set of psychological symptoms (e.g.,

anxiety or depression); and (d) offer equal amounts of treatment to

clients in the religion-accommodative and standard treatments.

Five published studies and one unpublished dissertation (W. B.

Johnson, 1991), which was later reported in W. B. Johnson,

DeVries, Ridley, Pettorini, and Peterson (1994), met these inclusion

criteria. Several studies that investigated religious approaches

to psychological treatment (e.g., Azhar & Varma, 1995a, 1995b;

Azhar, Varma, & Dharap, 1994; Carlson, Bacaseta, & Simanton,

1988; Richards, Owen, & Stein, 1993; Rye & Pargament, 1997;

Toh & Tan, 1997) were obtained, but these studies failed to meet all

four inclusion criteria. Thus, they were omitted from the metaanalytic

sample. A single rater determined which studies met

inclusion criteria. This rater’s decisions were made without reference

to the results or discussion sections of the articles.

The resulting meta-analytic sample included five studies representing

data from 111 counseling clients. Descriptions of study

populations, measures used, and effect size estimates (with 95%

confidence intervals) are given in Table 1.

The Studies

Researchers interested in accommodative forms of religious

counseling have taken standard cognitive-behavioral protocols or

specific techniques, such as cognitive restructuring (Beck, Rush,

Shaw, & Emery, 1979), cognitive coping skills (Meichenbaum,

1985), and appeals to rational thinking (e.g., Ellis & Grieger, 1977),

and have developed religion-friendly rationales for and versions of

such protocols or techniques (W. B. Johnson & Ridley, 1992b).

These adapted protocols or techniques are thought to be theoretically

equivalent to standard cognitive-behavioral techniques (Propst,

1996), but more amenable to the religious world view and religious

language that religious clients use to understand their lives and

their problems. The five studies are described in greater detail next.

Propst (1980). Propst (1980) examined the differential efficacy

of a manualized, religion-accommodative approach to cognitive

restructuring and imagery modification. Volunteers who scored in

the mild or moderate range of depression on the Beck Depression

Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961)

and in at least the moderate range on the King and Hunt (1972)

religion scales were randomly assigned to one of two treatments.

The standard treatment was an integration of Beck’s (1976)

cognitive therapy for depression and Meichenbaum’s (1973) cognitive-

behavior modification. During eight 1-hr sessions conducted

over 4 weeks, clients were trained to observe their cognitions and

imagery during depressed moods. After clients were convinced of

the links between their moods, thoughts, and images, they practiced

cognitive restructuring skills for modifying their thoughts and

images using imagery and positive self-statements (e.g., “I can see

myself in the future coping with that particular situation”). Ten of

eleven clients assigned to this condition completed it.

In the religion-accommodative treatment, clients completed the

same therapeutic protocol as that used in the standard treatment.

The only difference is that participants were trained to replace their

negative cognitions and imagery with religious images (e.g., “I can

visualize Christ going with me into that difficult situation in the

future as I try to cope”). Seven of 9 clients assigned to this

condition completed the treatment.

Pecheur and Edwards (1984). Pecheur and Edwards (1984)

assessed the differential efficacy of Beck et al.’s (1979) cognitive

therapy for depression and a religion-accommodative version of

the same therapy. Clients were students from a Christian college

who met research diagnostic criteria for major depressive disorder.

Table 1

Sample Sizes, Effect Sizes, and 95% Confidence Intervals (Cl)for the Studies Included

in the Meta-Analysis


Propst (1980)

Pecheur & Edwards (1984)

Propst etal. (1992)

W. B. Johnson & Ridley (1992a)

W. B. Johnson et al. (1994)


treatment n





















95% CI







They also scored in the depressed range on the BDI, the Hamilton

Rating Scale for Depression (HRSD; Hamilton 1960), and a

single-item visual analogue scale. In the standard treatment, clients

completed eight 50-min sessions of cognitive behavior modification.

All 7 clients who were assigned to this treatment completed it.

In the religion-accommodative treatment, clients completed the

standard cognitive therapy tasks specified in Beck et al. (1979);

however, challenges to negative cognitions were placed in a

religious context. For example, rather than replacing negative

views of self with statements such as “Our self-acceptance and

self-worth are not lost or lessened when we fail,” the religionaccommodative

approach trained clients to use self-statements

such as, “God loves, accepts, and values us just as we are.” This

treatment was also administered according to a manual, which

appears in Pecheur (1980).

Propst, Ostrom, Watkins, Dean, and Mashburn (1992). Propst

et al. (1992) compared the efficacy of Beck et al.’s (1979) cognitive

therapy for depression with a manualized, religion-accommodative

version of the same therapy (see Propst, 1988). Clients were

recruited from the community and scored at least 14 on the 28-item

version of the HRSD. They also scored at least in the moderate

range on standard measures of religious commitment (e.g., Allport

& Ross, 1967; King & Hunt, 1972). Clients in the standard

treatment completed 18 sessions of individual cognitive therapy for

depression. All 19 clients enrolled in this condition completed it.

In the religion-accommodative treatment, clients completed 18

sessions of cognitive therapy that challenged negative cognitions

and images by replacing them with positive thoughts and imagery

of a religious nature, as in Propst (1980). All 19 clients enrolled in

this condition completed it.

W. B. Johnson & Ridley (1992a). Johnson and Ridley (1992)

compared the efficacy of rational-emotive therapy (RET), using

Walen, DiGiuseppe, and Wessler’s (1980) treatment manual, with a

manualized, religion-accommodative version of the same therapy.

Clients were theology students and local church members who

scored in at least the mildly depressed range on the BDI. They also

scored in the “intrinsic” range on a standard measure of religious

motivation (Allport & Ross, 1967), suggesting that their religious

faith was highly internalized. In the standard RET condition, clients

completed six 50-min sessions in 3 weeks, including homework

sessions and in-session rehearsal of rational-emotive techniques.

All 5 clients assigned to this condition completed it.

In the religion-accommodative treatment, three explicitly Christian

treatment components were added. First, clients were directed

to dispute irrational beliefs using explicitly Christian beliefs, as in

Propst (1980). Second, clients were encouraged to use Christian

prayer, thoughts, and imagery in their homework assignments.

Third, counselors used brief prayers at the end of each session. All

5 clients assigned to this condition completed it.

W. B. Johnson et al. (1994). W. B. Johnson et al. (1994)

compared the efficacy of standard RET and a religion-accommodative

form of RET, as in W. B. Johnson and Ridley (1992a).

Selection criteria were almost identical to those reported in W. B.

Johnson and Ridley (1992a). The standard RET condition was an

eight-session protocol delivered over 8 weeks, and was based on

two popular RET treatment manuals (Ellis & Dryden, 1987; Walen

et al., 1980). All 16 clients assigned to this condition completed it.

The religion-accommodative treatment was based on two treatment

manuals discussing Christian versions of RET (Backus, 1985;

Thurman, 1989). Although the basic structure of RET was kept

intact, clients were encouraged to dispute irrational beliefs based

on scriptural beliefs and biblical examples. Homework assignments

also used biblical examples and beliefs. All 16 clients

assigned to this condition completed it.

Effect Size Estimates

Effect sizes and homogeneity statistics were calculated from

means and standard deviations using the DSTAT statistical software,

Version 1.10 (B. T. Johnson, 1989), using the formulas

prescribed by Hedges and Olkin (1985). Effect sizes were based on

the difference between the mean of clients in the standard

counseling condition and the mean of clients in the religionaccommodative

conditions. This difference was divided by the

pooled standard deviation of clients in both conditions. All effect

size estimates, expressed as d+ values, are corrected for the bias

that is present in uncorrected g values, as recommended by Hedges

and Olkin (1985). Effect sizes can be interpreted as the increased

amount of symptom reduction afforded to participants in the

religion-accommodative condition, expressed in standard deviation

units. In calculating aggregate effect size estimates, individual

effect sizes were weighted by the inverse of their sampling error

variance, so that studies with larger samples were given greater

weight in the calculation of d+ (Hedges & Olkin, 1985).

The Q statistic was also used to estimate the degree of variability

among the effect sizes. The Q statistic is basically a goodness-of-fit

statistic with a roughly x2 distribution that enables a test of the

hypothesis that all observed effect sizes were drawn from the same

population. Significant Q values imply a heterogeneous set of effect

sizes (Hunter & Schmidt, 1990).

Handling Multiple Dependent Measures

All five studies used the BDI as a dependent measure of

depression. Although two of the studies also used the HRSD or a

single-item visual analogue measure of depression, or both (Pecheur

& Edwards, 1984; Propst et al., 1992), effect size estimates

were based exclusively on the BDI for three reasons. First, the BDI

has been shown to produce conservative effect size estimates in

comparison to rating scales that are completed by clinicians, such

as the HRSD (Lambert, Hatch, Kingston, & Edwards, 1986).

Second, single-item visual analogue measures of depression (e.g.,

Aitken, 1969) appear to contain remarkably little true score

variance (Faravelli, Albanesi, & Poli, 1986). Third, the aggregation

of data across multiple dependent measures requires knowing their

intercorrelations, which were not available for all five studies.

Thus, the individual and mean effect size estimates reported here

can be considered to be somewhat conservative.

Handling Data From Multiple Follow-Up Periods

All five studies collected follow-up data within 1 week of the

termination of the trial. Although three of the studies (W. B.

Johnson et al., 1994; Pecheur & Edwards, 1984; Propst et al., 1992)

also reported follow-up data collected between 1 and 3 months

after the termination of the trial, and one study (Propst et al., 1992)

reported an effect size for a 24-month follow-up, we based our

effect size estimates only on the data from the 1-week follow-up.

Other Problems With Coding Effect Sizes

Some studies reported data on additional experimental conditions,

including self-monitoring and therapist contact conditions

(Propst, 1980), waiting list control conditions (Pecheur & Edwards,

1984; Propst et al., 1992), and pastoral counseling conditions

(Propst et al., 1992). Because none of these conditions were

relevant to the central goal of this study, these data were neither

coded nor included in the present meta-analytic study.


Two other problems arose in coding effect sizes. First, although

Propst (1980) reported posttreatment means on the BDI for both

conditions, standard deviations were not reported. On the basis of

the assumption that the other four studies in the present metaanalysis

would yield similar pooled standard deviations for the

BDI, a mean standard deviation for posttest scores on the BDI from

these studies (5.81) was used as an imputed standard deviation for

Propst (1980). This imputed standard deviation produced a nonsignificant

test statistic for the comparison of the religious and

standard counseling conditions, as Propst (1980) reported, giving

us confidence that our imputed standard deviation was not wholly


Second, Propst et al.’s (1992) results reported treatment effects

separately for religious and nonreligious therapists, which was an

independent factor in their experimental design. To collapse

treatment effects across levels of the therapist religiousness factor,

means and standard deviations obtained for religious and nonreligious

therapists within each of the two religious counseling

conditions were pooled before calculating an effect size for the


Corrections of Findings for Unreliability

in Dependent Measures

Scholars in meta-analysis advise that effect size estimates be

corrected for biases (Hunter & Schmidt, 1990, 1994). One of the

easiest biases to correct is attenuation resulting from unreliability

in the dependent variable. This bias can be corrected by dividing

observed effect sizes and standard errors by the square root of the

internal consistency of the dependent variable. Because metaanalytic

estimates of the BDI’s internal consistency were readily

available (Beck, Steer, & Garbin, 1988, estimated its internal

consistency at a = .86), the observed mean effect size and its

confidence interval (CI) were divided by the square root of .86, or

.927. Corrections for attenuation resulting from unreliability of the

dependent variable produce increased effect size estimates but also

a proportionate increase in confidence intervals; thus, a nonsignificant

effect size will not become significant as a result of this

correction (Hunter & Schmidt, 1994).

Estimating Clinical Significance

We were also interested in whether religion-accommodative and

standard approaches to counseling yielded clinically significant

differences in efficacy (Jacobson & Revenstorf, 1988; Jacobson &

Truax, 1991). Thus, we calculated meta-analytic summaries of

clinical significance for two studies that reported clinical significance

data (using BDI > 9 as a cutoff for “mild clinical depression”;

Kendall, Hollon, Beck, Hammen, & Ingram, 1987).


Observed Mean Effect Size and Attenuation-Corrected

Effect Size

The mean effect size for the difference between religious

and standard counseling during the 1-week follow-up period

(number of effect sizes = 5, N = 111) was d+ = +0.18

(95% CI: -.20/+0.56), indicating that clients in religionaccommodative

counseling had slightly lower BDI scores at

1-week follow-up than did clients in standard counseling

conditions. This effect size was not reliably different from

zero (p = .34). The five effect sizes that contributed to this

mean effect size were homogeneous, Q(4) = 5.38, p > .10.

The mean effect size after correcting the effects for attenuation

resulting from unreliability was d+ = +0.20 (95% CI:


Differences in Clinical Significance

Two studies (W. B. Johnson & C. R. Ridley, 1992a;

Propst, 1980) reported the percentage of participants in the

religious and standard psychotherapy conditions who manifested

evidence of at least mild clinical depression (BDI

scores >9) during the 1-week follow-up period. Aggregation

of these data indicated that, among the 20 religionaccommodative

counseling clients in the two studies, 4

(20%) were still at least mildly depressed at the end of

treatment. Among the 26 standard counseling clients in the

two studies, 9 (34.6%) were at least mildly depressed when

treatment ended. This difference clinical significance was

not statistically significant, x2(l, N = 46) = 1.19,p > .10.


The goal of the present study was to review the existing

empirical evidence regarding the comparative efficacy of

religion-accommodative approaches to counseling depressed

religious clients. These data suggest that, in the

immediate period after completion of counseling, religious

approaches to counseling do not have any significant

superiority to standard approaches to counseling. Given that

the differences in efficacy of most bonafide treatments are

surprisingly small (e.g., Lambert & Bergin, 1994; Wampold,

1997), the existing literature on psychotherapy outcomes

would have portended the present meta-analytic results.

These findings corroborate some narrative reviews that

claim equal efficacy for religion-accommodative and standard

approaches to counseling (e.g., Worthington et al.,

1996), and help to resolve the inconsistencies that others

have observed among these studies (e.g., W. B. Johnson,

1993; Matthews et al., 1998).

Although it is true that the religious approaches to

counseling were no more effective than the standard approaches

to counseling, it is equally true that they were no

less effective than the standard approaches to counseling.

Thus, the decision to use religion-accommodative approaches

might be most wisely based not on the results of

comparative clinical trials, which tend to find no differences

among well-manualized treatments, but rather on the basis

of patient choice (see Wampold, 1997). Not every religious

client would prefer or respond favorably to a religionaccommodative

approach to counseling. Indeed, the available

evidence suggests that all but the most highly religious

clients would prefer an approach to counseling that deals

with religious issues only peripherally rather than focally

(Wyatt & Johnson, 1990; see Worthington et al., 1996, for


On the other hand, many religious clients—especially

very conservative Christian clients—would indeed be attracted

to a counseling approach (or counselor) precisely

because the counseling approach (or the counselot) main96


tained that the clients’ system of religious values were at the

core of effective psychological change (Worthington, et al.,

1996). The research reviewed herein indicates that no

empirical basis exists for withholding such religionaccommodative

treatment from depressed religious clients

who desire such a treatment approach.

The Last Word?

There is inherent danger in publishing meta-analytic

results. Because of their ability to provide precise-looking

point estimates and short CIs (especially when the observed

effect size estimates are relatively heterogeneous), metaanalytic

summaries can be perceived to be the last word in

evaluating research questions. It would be unfortunate if the

present results were interpreted as the last word in evaluating

the efficacy of religious approaches to counseling, however,

because interesting and important questions remain.

For example, although religion-accommodative approaches

to counseling do not appear to be differentially

efficacious in reducing symptoms (at least depressive symptoms),

they might produce differential treatment satisfaction

among some religious clients. Also, comparative studies of

religion-accommodative therapy are needed with longer

follow-up periods. It is possible that religion-accommodative

approaches might prove to be superior to standard

treatments in longer term follow-up periods, particularly in

helping clients from relapsing, for example, back into

depressive episodes. The differential effects of religionaccommodative

and standard approaches to treatment also

need to be investigated for a wider variety of disorders,

including anxiety, anger, alcohol and drug problems, and

marital and family problems. As well, although religionaccommodative

and standard approaches to counseling do

not appear to influence clients’ religiousness or religious

values differentially (Worthington et al., 1996), it is possible

that religion-accommodative counseling yields differential

improvements in religious clients’ spiritual well-being.

Finally, on a technical note, it should be noted that the

studies in this body of literature currently have been

seriously underpowered (i.e., in all cases fewer than 20

clients per treatment). This literature would benefit enormously

from as few as three or four very high-quality,

large-sample (i.e., 30 or more clients per condition) studies

that investigated these questions in greater detail. W. B.

Johnson (1993) provided other helpful methodological recommendations

to which research on religion-accommodative

counseling should adhere.


The stability of meta-analytic findings comes from the

number of studies included in the meta-analysis as well as

the number of participants in the constituent studies. Thus,

the findings from meta-analyses with small numbers of

studies, such as the present study, are more easily overturned

than meta-analyses that include larger numbers of studies.

Although meta-analytic methods can be used to synthesize

the results of as few as two studies (for examples of small-it

meta-analyses, see Allison & Faith, 1996; Benschop et al.,

1998; Kirsch, Montgomery, & Sapirstein, 1995; Uchino,

Cacioppo, & Kiecolt-Glaser, 1996), our findings would

obviously be considered more trustworthy if more studies

had been available.

A second limitation of the present findings relates to the

nature of the meta-analytic sample. The five studies reviewed

herein all investigated religion-accommodative counseling

with depressed Christian clients. We can only speculate

whether the present pattern of results would generalize

to different religious populations or to people with different

sets of presenting problems. Obviously, research is needed

to fill in such gaps.


A variety of empirical data now suggest that certain forms

of religious involvement can help prevent the onset of

psychological difficulties and enhance effective coping with

stressors. In addition, the majority of mental health professionals

and the general public believe that patients’ religious

beliefs should be adequately assessed and taken into consideration

in mental health treatment. Moreover, data indicate

that patients’ religious commitments can play a substantial

role in counseling processes (Worthington et al., 1996). Data

from the present study also indicate that religious approaches

to counseling can be as effective as standard

approaches to counseling depressed persons. Thus, for some

clients, particularly very religious Christian clients, religionaccommodative

approaches to counseling could be, quite

literally, the treatment of choice. It is hoped that the present

study will encourage counseling psychologists to examine

whether religion-accommodative approaches yield similar

or even superior benefits on other important metrics of

therapeutic change and with other common difficulties in



References marked with an asterisk indicate studies included in the


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