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Spiritually Integrated Psychotherapies in Real-World Clinical Practice: Synthesizing the Literature to Identify Best Practices and Future Research Directions

Authors:
Laura Captari at Boston University
Laura Captari
Steven j. Sandage at Boston University
Steven j. Sandage
Richard A. Vandiver
Richard A. Vandiver
Richard A. Vandiver
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Abstract

A comprehensive review of the practice-based evidence for spiritually integrated psychotherapy (SIP) is necessary in order to catalyze research and training in this important diversity area. In this article, we identify and synthesize key findings from 35 studies in six key areas: (a) SIPs in trauma treatment, (b) SIPs in treating eating disorders, (c) SIPs in general psychotherapy, (d) existential concerns as part of SIPs, (e) patients and therapist attitudes about SIPs, and (f) SIP supervision and training models. Building on this, we propose a culturally contextual understanding of this diversity area, drawing from the Relational Spirituality Model (RSM). Finally, we discuss best practices for spiritually responsive clinical care and offer a research prospectus to strengthen the evidence base for real-world effectiveness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Spiritually Integrated Psychotherapies in Real-World Clinical
Practice: Synthesizing the Literature to Identify Best
Practices and Future Research Directions
Laura E. Captari
1
, Steven J. Sandage
1, 2
, and Richard A. Vandiver
1
1
The Albert and Jessie Danielsen Institute, Boston University
2
MF Norwegian School of Theology, Religion, and Society, Oslo, Norway
A comprehensive review of the practice-based evidence for spiritually integrated psychotherapy (SIP) is
necessary in order to catalyze research and training in this important diversity area. In this article, we identify
and synthesize key findings from 35 studies in six key areas: (a) SIPs in trauma treatment, (b) SIPs in treating
eating disorders, (c) SIPs in general psychotherapy, (d) existential concerns as part of SIPs, (e) patients and
therapist attitudes about SIPs, and (f) SIP supervision and training models. Building on this, we propose a
culturally contextual understanding of this diversity area, drawing from the Relational Spirituality Model
(RSM). Finally, we discuss best practices for spiritually responsive clinical care and offer a research
prospectus to strengthen the evidence base for real-world effectiveness.
Clinical Impact Statement
Question: In what ways are clients’spirituality, religion, theology, and/or existential concerns relevant
in real-world mental health treatment? Findings: Clients’spiritual and religious context have important
implications for their symptom alleviation and well-being, and may intersect with other areas of their
identity. Meaning: Therapists should consider spirituality as an important diversity area that may be a
source of strength or struggle for clients. Next Steps: Ongoing research is needed to understand the
nuances of how clients’spirituality is best integrated into psychotherapy with different populations.
Keywords: spirituality, religion, psychotherapy, practice-based evidence
Supplemental materials: https://doi.org/10.1037/pst0000407.supp
Research suggests that many patients would like to engage spiritual
and/or religious issues as part of their mental health treatment if
confident their providers would be accepting of their values and
perspectives (Harris et al., 2016). Broadening to an inclusive frame-
work of Spiritual, Existential, Religious, and Theological dimensions
of experience (SERT; Sandage, Rupert, et al., 2020), we notice that
despair and hope, emptiness and vitality, mortality and meaning, and
many similar themes are salient in psychotherapy. The capacity to
skillfully adapt treatment to patients’values and practices is an
important aspect of culturally competent clinical practice, yet SERT
experience has historically been neglected, oversimplified, or avoided,
often seen as the purview of religious leaders rather than psychothera-
pists (Sperry, 2012). Some patients may be initially hesitant to discuss
SERT concerns and wait for their therapist to ask, wondering if this is
relevant in a presumed “secular”or “medical”environment (Oxhandler
et al., 2018). Furthermore, patients’SERT perspectives often intersect
with their race, ethnicity, nationality, gender, sexual orientation, and
social location in ways that intensify minority stress and increase
discrimination in healthcare settings. The nuances of intersectionality
can challenge therapists’spiritual and religious competence, and few
clinicians appear to receive adequate clinical training in this diversity
area (Oxhandler & Parrish, 2018;Vieten & Scammell, 2015). Despite
these clinical complexities, a well-established outcome literature has
documented the efficacy of integrating patients’SERT concerns in
randomized controlled treatment settings. In a meta-analysis of 97
experimental and quasi-experimental studies, spiritually integrated
psychotherapies (SIPs) facilitated a greater sense of spiritual well-
being compared to standard approaches and promoted equivalent
symptom reduction (Captari et al., 2018). This body of literature helps
make the case for the clinical legitimacy of SIPs in mental health
treatment and the possibility of enhanced impact on areas of spiritual
functioning that can be important to many patients. Moreover, a
growing body of research shows that patients’psychosocial
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Editor’s Note. Philip Scott Richards served as the action editor for this
article.—JO
This article was published Online First November 29, 2021.
Laura E. Captari https://orcid.org/0000-0002-1188-2462
This project was supported by a grant from John Templeton Foundation on
“Mental Healthcare, Virtue, and Human Flourishing”(#61603).
Laura E. Captari played a lead role in conceptualization, project adminis-
tration, and writing of original draft. Steven J. Sandage played an equal role
in conceptualization, project administration, and writing of review and
editing. Richard A. Vandiver played a supporting role in methodology
and writing of review and editing.
Correspondence concerning this article should be addressed to Laura E.
Captari, TheAlbert and Jessie Danielsen Institute,Boston University, 185 Bay
State Road, Boston, MA 02215, United States. Email: lcaptari@bu.edu
Psychotherapy
© 2021 American Psychological Association 2022, Vol. 59, No. 3, 307–320
ISSN: 0033-3204 https://doi.org/10.1037/pst0000407
307
... The rise of attention toward S/R in psychotherapy has led to the development of spiritually and religiously accommodative psychotherapies (Captari et al., 2022). Psychotherapy outcome research has thoroughly documented the efficacy of these spiritually integrated psychotherapies, and while they seem to be equivalent to standard psychotherapies for psychological outcomes, in cases with S/R clients, these tend to be more effective than secular approaches (for a review, see Bouwhuis-Van Keulen et al., 2024). ...
... Thus, to provide competent care, psychotherapists may need to address certain beliefs or practices explicitly (Saunders et al., 2010). Captari et al. (2022) reviewed the literature on spiritually integrated psychotherapies and summarized topics in which S/R plays a central role, including trauma, PTSD, eating disorders, depression, existential concerns, and end of life. In another review of the literature on S/R and health, Koenig (2012) added depression, suicide, anxiety, psychosis, and substance abuse to the list. ...
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Spirituality and religiousness (S/R) are multicultural issues that have a complicated historical relationship with psychotherapy. This study aimed to synthesize the findings of qualitative studies focused on how psychotherapists experience S/R in psychotherapy. A sample of 52 primary qualitative studies was identified through database searches and subsequent manual searches of literature. The findings of primary studies were extracted and aggregated using qualitative meta-analysis. The experiences of S/R were summarized in 11 metacategories organized into three clusters, namely, relationship between psychotherapists’ spiritual/religious and professional identity, spirituality/religiousness in session, and a spiritual/religious psychotherapist in the broader field of psychotherapy. Psychotherapists’ experiences with S/R are reflected in psychotherapists’ identities as well as in the psychotherapy process. Implications for psychotherapeutic practice, training, and supervision are discussed.
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... Accreditation bodies in these fields have universally identified religion in particular as a core area of multicultural diversity (American Psychological Association, 2015; Council for Accreditation of Counseling and Related Educational Programs, 2016;Council on Social Work Education, 2015). In keeping with the evidence-based practice movement, mental health professions also have an increasing number of scientific studies documenting the prevalence of S/R (Pew Research Center, 2022), salubrious (Balboni et al., 2023;Koenig et al., 2023) and potentially iatrogenic (Bockrath et al., 2022) dimensions of S/R, validated methods for assessing S/R (Hill & Edwards, 2013), and effectiveness of psychotherapies that integrate clients' S/R (Captari et al., 2018(Captari et al., , 2021. However, empirical and anecdotal sources indicate that many graduate programs are altogether neglecting to cover S/R or struggling to formally include such content in their curricula in effective ways (S. ...
Faculty Perspectives on Addressing Spiritual and Religious Competencies in Mental Health Graduate Education
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Addressing spirituality and religion (S/R) in graduate education closely aligns with multiculturalism, intersectionality, evidence-based practice, and other movements and frameworks (e.g., whole-person care, trauma-informed care, person-centered care) that will continue to guide mental health care in the third millennium. Defined as basic attitudes, knowledge, and skills related to S/R that mental health professionals will ideally pursue to effectively and ethically practice in an increasingly pluralistic society, spiritual and religious competencies are frequently neglected in counseling, health service psychology, social work, and other programs. In turn, students might wrongly assume that S/R are not relevant to their work, feel discomfort with discussing peoples’ S/R, perpetuate bias against religious or secular persons, or have an incomplete picture of peoples’ flourishing and suffering throughout their professional careers. Building on the Spiritual and Religious Competencies Project, the purpose of this special section was to facilitate interdisciplinary dialogue and engagement on critical targets, challenges, and solutions for addressing S/R in graduate education. Namely, eight university administrators and training leaders in their respective professions were invited to discuss the (a) roles of S/R in diversity, identity, and psychological functioning; (b) facets of S/R competence to target in their programs; (c) barriers, problems, and concerns about training students in spiritual and religious competencies; and (d) facilitators, opportunities, and strategies for overcoming such issues. Notwithstanding varying views and disciplinary differences, authors also highlighted shared challenges for addressing S/R in their contexts along with practical solutions that might promote larger systems change across mental health professions.
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... Mental health clients' religion/spirituality (R/S) are increasingly recognized as important to consider within treatment. There is a growing recognition of the positive impact such integration has on treatment outcomes for clinical issues (Captari et al., 2022;Goncalves et al., 2015;Koenig et al., 2023, Smith et al., 2007. Increasingly, researchers and clinicians acknowledge R/S's nuanced nature, including both positive and negative religious coping strategies (Pargament, 2007), spiritual struggles (Pargament & Exline, 2022), spirituality as a source of comfort and resilience , R/S-related social supports, religious trauma, and more. ...
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... Considering this, mental health treatment focusing on symptoms alone misses important aspects of trauma survivors' experience that may underlie limited well-being and flourishing. Increased attention to religious, spiritual, and existential domains as a distinct target of assessment and intervention can increase client engagement, communicate that clients are more than their symptoms, and improve holistic functioning (Captari et al., 2022). Evidence for the unique contribution of R/S struggles to low well-being and the salience of meaning-making have been previously documented in general clinical This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
Trauma Survivors’ Spiritual Struggles and the Anger of Hope: A Practice-Based Clinical Study Examining Links With Mental Health Symptoms and Well-Being
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In addition to psychological distress, trauma survivors often grapple with religious/spiritual (R/S) struggles, which can compromise well-being and limit possibilities for flourishing. This practice-based clinical study of psychotherapy clients (N = 349) in a community mental health clinic compares clients reporting histories of trauma (n = 149) with a general clinical subsample (n = 200), exploring the interplay between R/S struggles and anger with symptom distress and well-being outcomes. Trauma survivors reported significantly higher levels of anger and both interpersonal and moral R/S struggles than other clients, reinforcing the need for careful attention to these domains in trauma-focused psychotherapy. Regression analyses revealed that anger accounted for unique variance in predicting R/S struggles with meaning, even after controlling for posttraumatic stress and depression, indicating the importance of understanding the complex functions of trauma-related affects (e.g., anger, shame) and formulating working through such emotion as closely linked with R/S struggles. Regressions also found evidence that—over and above mental health symptomology—R/S struggles accounted for unique variance in predicting survivors’ sense of compromised well-being and limited flourishing, orienting therapists to the centrality of R/S struggles as a driving, but oft-neglected, force that may impede recovery. Limitations, future directions, and best practices for integrating R/S in trauma-focused psychotherapies are discussed.
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... We also now have substantial evidence that (a) spiritual resources can contribute substantially to trauma recovery (Bryant-Davis & Wong, 2013;Koenig, 2020) and that (b) spiritual struggles and distress can compound mental health challenges and impede healing (including healing from adverse or traumatic R/S experiences; Ellis et al., 2022;Zaeske et al., 2024). Furthermore, attention to developmental and relational R/S dynamics offers nuance in understanding how, and in what ways, trauma survivors may engage R/S as a context for dwelling (e.g., comfort, grounding, connection, purpose) and/or seeking (e.g., curiosity, learning, growth; Captari et al., 2022;Sandage et al., 2020). ...
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... Not only are RS important to consider as part of client diversity, but recent studies highlight that addressing clients' RS in mental health treatment has positive outcomes. For example, consideration of clients' RS in treatment has been linked to lower levels of anxiety (Koszycki et al., 2014;Rosmarin et al., 2010), depression (Koenig et al., 2015), migraines (Wachholtz & Pargament, 2008), and many other physical and mental health issues (Captari et al., 2021;Koenig et al., 2023). Further, several studies indicate a positive impact from incorporating RS into treatment of post-traumatic stress disorder (PTSD) both in veterans and with those experiencing moral injury as part of PTSD (Ames et al., 2021;Harris et al., 2018;Pearce et al., 2018). ...
Helpful and Harmful Approaches to Integrating Religion and Spirituality into Mental Health Care: A National Survey of Current Clients’ Experiences in the United States
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This article describes a national sample of 989 current mental health clients’ views regarding whether and how their mental health care providers integrated the client’s religion/spirituality (RS) into treatment. Within the online Qualtrics survey, two open-ended items asked respondents what (if anything) the client perceived their therapist having done regarding the client’s RS that was (1) helpful/supportive or (2) hurtful/harmful. Participants also reported various ways therapists included the topic of RS in practice, if any. Nearly half freely described helpful ways their providers integrated the client’s RS, and half indicated it was not discussed or applicable. Although 9.6% described hurtful experiences, most indicated their provider had not done anything harmful related to integrating RS. Implications for practice and training across mental health disciplines are discussed.
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... However, for individual religious patients it may be valuable to incorporate their religiousness into therapy. For this group the incorporation seems to be at least equally effective as regular therapy when it comes to psychological outcomes (Anderson et al., 2015;Bouwhuis-van Keulen et al., 2023;Captari et al., 2018), but may also enhance the treatment alliance (Van Nieuw Amerongen-Meeuse et al., 2020) and may lead to recovery on other domains as well (e.g., spiritual well-being; Captari et al., 2018;2022). ...
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... Specifically, while religion and spirituality is often overlooked in assessment and treatment and many clinicians feel unprepared to address it (Oxhandler et al., 2019;Pargament, 2011;, a large portion of patients desire to integrate religion and spirituality into clinical treatments (Oxhandler et al., 2021). Previous research suggests that a wide variety of evidence-based modalities can successfully incorporate religion and spirituality (Captari et al., 2022;Vieten & Lukoff, 2022), and that among religious patients, such treatments may be effective than secular psychotherapies (Worthington et al., 2011). Moreover, religion and spirituality appears to be highly relevant to the vast majority of the world population (Pew Research Center, 2022), and ignoring this important domain may interfere with both alliance and successful treatment (Terepka & Hatfield, 2020). ...
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This paper surveys the current understanding of spiritually integrated psychotherapy (SIP) and connects the historical role of religious training to better understand how SIP is developing as a psychotherapy modality in Ontario, Canada. The paper clarifies how SIP is defined and proposes three levels of practice: spiritually conscious therapy, spiritually informed therapy, and spiritually integrated therapy. As evidence-based and practiced-based literature expands, more consensus is needed in how SIP terminology is used.
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Access to adequate, much less state-of-the-art, mental health care is a global problem. Natural disasters, civil war, and terrorist conflict have forcibly displaced millions of Muslims and have resulted in a remarkable level of individual and communitywide trauma exposure. As a result, many are at risk for posttraumatic stress and other trauma-related disorders. Many religiously oriented Muslims traditionally rely on Islamic principles and teachings, as well as their community, to cope with and address trauma-related distress. Islamic Trauma Healing is a six-session, lay-led group intervention developed within a Somali Muslim community that integrates evidence-based trauma-focused cognitive-behavioral therapy principles with cultural and religious practices aimed to enhance uptake and create an easily up-scalable intervention for a wide range of trauma. In sessions, narratives of prophets who have undergone trauma (e.g., Prophet Ayyub, faith during hard times) present Islamic principles and facilitate cognitive shifts. Group members spend individual time turning to Allah in dua (i.e., informal prayer), focused on exposure to trauma memories. Program themes arc across suffering to healing to growth following trauma. This paper describes the core theoretical principles and methods in the Islamic Trauma Healing program. We also describe leader perspectives and the program’s train-the-trainer model, in which lay leaders are trained to further disseminate the program and allow Islamic Trauma Healing to be owned and sustained by the Muslim community.
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Spiritual bypass denotes a process by which an individual avoids painful psychological experiences by using spirituality as a defense. Although spiritual bypass is often detected within psychological treatment, it has only recently been studied empirically. In the current study, we extend the study of spiritual bypass by testing (a) its associations with religious commitment, spirituality, attitudes toward God, and psychological as well as medical help-seeking attitudes and (b) direct and indirect relationships using bias-corrected, boot-strapped confidence intervals using a model recommended by Hayes (2018). In Study 1, we surveyed 265 community-based adults recruited from Amazon’s Mechanical Turk (MTurk). Religious commitment and spirituality were directly related to attitudes toward psychological help-seeking. However, these relationships were indirectly associated with spiritual bypass. In Study 2, we surveyed 199 undergraduate students and found that attitudes toward God (i.e., positive attitudes toward or disappointment and anger with God) were related to medical help-seeking attitudes. Likewise, these relationships were indirectly associated with spiritual bypass. The implications were that (a) religious and spiritual variables relate to help-seeking attitudes; (b) religious and spiritual associations with help-seeking are both directly and indirect associated with spiritual bypass, and additional research is needed to uncover precise conditions under which spiritual bypass might or might not causally affect these relationships (i.e., investigate potential moderators and mediational effects); and (c) in practice, spiritual bypass can be an important patient quality to consider in relation to an individual’s attitudes toward and perhaps benefit from psychological help.
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Religious and spiritual struggles and mental health: Implications for clinical practice
Chapter
  • Jul 2021
This chapter reviews the growing literature on religious and spiritual (R/S) struggles and their implications for clinical practice, with a focus on people with psychiatric problems. The empirical literature indicates that R/S struggles: (a) take a variety of forms that reflect tensions and conflicts around the sacred; (b) are not uncommon among people with psychological problems; (c) are robust predictors of poorer mental health; (d) may be a cause and/or effect of psychological problems; and offer the potential for positive psychological growth and transformation, depending on how they are understood and handled. Practical recommendations are then offered to help psychiatrists draw on basic clinical skills to assess and address R/S struggles in treatment. Specifically, this chapter considers how practitioners can help patients name and normalize their struggles, accept and reflect on these conflicts, and access R/S resources that offer potential resolutions to their struggles.
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Intersectionality as a radical framework for transforming our disciplines, social issues, and the world
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In this introduction to the special issue on Applications of Intersectionality to Critical Social Issues, we assert that a psychological study of social issues that seeks to move toward social justice, equity, and liberation must embrace intersectionality's radical core. This requires constant critical inquiry and praxis centered on power, including how we shape power and how power shapes us. The both/and logics of intersectionality are particularly essential, as we can exist in both oppressive and liberatory ecosystems simultaneously, and we must reflect and act on this to achieve intersectionality's transformative potential. We outline ways that the articles in this special issue offer ways of “doing” intersectionality in psychology and allied fields, while also acknowledging the issue's limitations and potential replication of the status quo. We also offer personal reflections on our journeys with intersectionality in hopes of contributing to radical transformation of ourselves, our disciplines, social issues, and the world. © 2020 The Society for the Psychological Study of Social Issues
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Many counselors integrate meditation into treatment with clients. Although meditation can be presented as a secular practice, it also holds spiritual and religious relevance for many faith communities. In this article, we explore the use of Jewish meditation as a spiritually oriented treatment intervention with Jewish clients. Literature examining the relationships among counseling, the Jewish population, and Jewish meditation is presented. This article also includes practical considerations for integrating Jewish meditation into counseling.
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A practice‐based evidence investigation of God representations in spiritually integrated psychotherapies
Article
  • Oct 2020
Objective This practice‐based evidence study examined trajectories of God representations and psychological distress among Christians participating in spiritually integrated psychotherapies (SIPs). Methods In total, 17 clinicians practicing SIPs in a mid‐sized city on the US Gulf Coast implemented session‐to‐session assessments of these outcomes with 158 clients over a 4‐month period and also reported their use of specific spiritual interventions after each session (e.g., affirmed client's divine worth). Results Multivariate growth modeling revealed clients' psychological distress decreased over the study period whereas authoritarian God representations increased and benevolent God representations remained stable. In addition, clients who increased in benevolent representations of God had a greater likelihood of experiencing alleviation of psychological distress. Conclusion These findings affirm the potential efficacy of SIPs and cultural importance of belief in a benevolent deity as a source of strength, identity, and potential healing among Christians clients who prefer a spiritually integrated approach in psychotherapy.
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Testing a relational spirituality model of psychotherapy clients’ preferences and functioning
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  • Jul 2020
This study tested hypotheses about client preferences and functioning based on a relational spirituality model of psychotherapy in a sample (N = 101) of adult clients at a community mental health center in the northeastern United States. Most clients wanted to engage spiritual, religious, and existential issues in treatment and this preference was positively related to both spiritual/religious commitment and questing. Clients’ ratings of therapist diversity sensitivity were associated with ratings of treatment progress over and above the working alliance. Client spiritual well-being and spiritual struggles predicted their psychosocial functioning over and above mental health symptoms. Clinical and research implications are discussed.
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