Alcoholism is a major social problem. In the United States, the total economic costs to society from alcohol abuse have been estimated at $148 billion (Simon, Patel, & Sleed, 2005). According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2000a), over 700,000 Americans receive treatment for alcoholism on any given day. Treatment options have historically consisted of two relatively distinct alternatives: mutual aid groups (for example, Alcoholics Anonymous [AA]) and professional treatment (for example, mental health centers) (Magura, 2007).
Among professional treatments, one of the more effective approaches used to treat alcoholism is cognitive-behavioral therapy (CBT) (Longabaugh et al., 2005). Despite the effectiveness of CBT with some clients, this and other treatment modalities are ineffective with many others wrestling with alcohol dependency (Corte, 2007). Furthermore, among those who successfully complete treatment, relapse is often a problem (Corte, 2007; Piderman, Schneekloth, Pankratz, Maloney, & Altchuler, 2007). In short, research on treatment effectiveness is still in its infancy, and additional work is needed to enhance outcomes.
One approach that may enhance outcomes, at least for some clients, is the incorporation of spirituality into traditional CBT protocols. Although spirituality is a common dimension in mutual aid groups, it is comparatively rare in professional treatment settings (Magura, 2007). A survey of addiction treatment professionals (N = 317) found that 84 percent believed that spirituality should be emphasized more in treatment (Forman, Bovasso, & Woody, 2001). The importance of incorporating spirituality into treatment is also reflected in recent changes instituted by the Joint Commission--the most prominent health care accrediting organization in the United States--which now requires behavioral health organizations providing addiction services to administer a spiritual assessment (Hodge, 2006b; Koenig, 2007).
The purpose of this article is to acquaint readers with spiritually modified CBT, an approach that may speed recovery, enhance treatment compliance, prevent relapse, and reduce treatment disparities by providing more culturally congruent services. Although most practitioners are interested in incorporating spirituality into treatment, they also report receiving little, if any, training on the topic during their graduate education (Sheridan, 2009). The need for content on spirituality seems particularly pressing in light of the Joint Commission's new requirements. If accrediting organizations are going to require service providers to explore client spirituality, then content on how to help clients operationalize their spiritual strengths is vital. Spiritually modified CBT incorporates clients' spiritual strengths in ways that build on existing practice knowledge and skill sets in the area of CBT (Longabaugh et al., 2005).
Toward this end, the research on spiritually modified CBT is reviewed, rationales for its applicability with alcohol treatment are provided, positive outcomes that may be enhanced are delineated, and the process of constructing spiritually modified CBT self-statements is described and illustrated. To help ensure that this process occurs professionally, suggestions are offered for working with client spirituality in an ethical manner. First, however, the terms spirituality and religion are defined, and the role of client preferences in enhancing outcomes is discussed.
SPIRITUALITY AND RELIGION: DISTINCT BUT OVERLAPPING CONSTRUCTS
Although spirituality and religion are often used interchangeably, they can be seen as distinct but overlapping constructs (Canda & Furman, 2010; Derezotes, 2006). Spirituality is commonly understood as a person's existential relationship with God or the Transcendent (Gallup & Jones, 2000; Gilbert, 2000), whereas religion is often viewed as an expression of the spiritual relationship in particular forms, beliefs, and practices that have been developed--in community--with others who share similar experiences of transcendent reality (Gotterer, 2001; Miller, 1998). At the risk of oversimplifying, spirituality emphasizes the personal, and religion emphasizes the corporate.
Conceptualized in this manner, most people are both spiritual and religious (Pargament, 2002). Although some people express their spirituality solely in individualistic terms, apart from others, most people, as social beings, express their spirituality in some type of religious setting (Marler & Hadaway, 2002; Scott, 2001). This setting may be more traditional (Catholic Church) or alternative (for example, in what some call New Age religion or the syncretistic movement).
Spirituality and religion can be understood as continuous constructs (Gallup & Jones, 2000; Miller, 1998). For some, spirituality and religion play a minimal or even nonexistent role (Scott, 2001). For others, at the opposite end of the continuum, spirituality and religion play a central role in informing people's worldviews (Gallup & Lindsay, 1999; Van Hook, Hugen, & Aguilar, 2001). It is for people on this end of the continuum that incorporating spirituality and religion into CBT may be particularly salient in enhancing effectiveness.
ROLE OF CLIENT PREFERENCES
Widespread agreement exists that clients' beliefs, values, and preferences play an important role in treatment effectiveness (Sue & Sue, 2008). Interventions typically reflect the worldviews of the individuals responsible for their design and development (Blume & de la Cruz, 2005; Gilligan, 1993). Adapting therapeutic strategies to take into account clients' unique cultural values may enhance outcomes (Castro, Nichols, & Kater, 2007).
As implied earlier, spirituality and religion play a motivating role in many people's existence (Gallup & Jones, 2000). For such individuals, life is viewed through a spiritual prism (Richards & Bergin, 2000; Van Hook et al., 2001). Decisions are guided by spiritual frames (Maslow, 1968). It is to be expected that many such individuals will prefer to incorporate spirituality into the therapeutic conversation (Hodge, 2004; Hodge & Williams, 2002).
Indeed, according to Gallup data reported by Bart (1998), 81 percent of the general public desire to have their spiritual values and beliefs integrated into the counseling process. Similarly, studies of various client samples have also found that most respondents want practitioners to incorporate their spiritual beliefs into the therapeutic enterprise (Arnold, Avants, Margolin, & Marcotte, 2002; Larimore, Parker, & Crowther, 2002; Mathai & North, 2003; Rose, Westefeld, & Ansley, 2001; Solhkhah, Galanter, Dermatis, Daly, & Bunt, 2009). For instance, in one therapeutic community devoted to helping clients (N = 322) overcome alcoholism and other types of chemical dependency, the authors found that 84 percent of clients wanted more emphasis on spirituality in treatment (Dermatis, Guschwan, Galanter, & Bunt, 2004).
These data suggest that many clients wrestling with alcoholism want to incorporate their spiritual and religious strengths into treatment. Although integrating spirituality and religion into CBT is innovative, it is not without precedent (Miller, 1998). Indeed, a number of studies have been conducted on CBT that has been modified to include clients' spiritual values.
RESEARCH ON SPIRITUALLY MODIFIED CBT
Spiritually modified CBT is a therapeutic modality in which standard CBT treatment protocols are modified with spiritual beliefs and religious practices drawn from clients' spiritual worldviews (Hodge, 2006a). The cognitive restructuring techniques and the behavioral assignments are identical to traditional CBT (Nielsen, 2004). However, once unproductive beliefs and behaviors are identified, they are replaced with salutary schema and actions drawn from clients' spiritual narratives (Ellis, 2000).
Although spiritually modified CBT has not been used to address alcoholism, it has been used with diverse groups to treat a variety of problems (Stoltzfus, 2008). For instance, Taoistically modified CBT has been used with clients wrestling with neurosis (Xiao, Young, & Zhang, 1998). CBT modified with tenets from the Latter Day Saint tradition has been used to treat perfectionism (Richards, Owen, & Stein, 1993). A generic spirituality has been used to help clients cope with stress (Nohr, 2000), depression (D'Souza, Rich, Diamond, Godfery, & Gleeson, 2002; D'Souza, Rodrigo, Keks, Tonso, & Tabone, 2003), and bipolar disorder (D'Souza et al., 2003).
Other studies have examined a number of issues among adherents of Christianity and Islam. CBT modified with Christian beliefs and practices has been used to address compulsive disorder (Gangdev, 1998) and, most notably, depression (Hawkins, Tan, &Turk, 1999; Johnson, Devries, Ridley, Pettorini, & Peterson, 1994; Pecheur & Edwards, 1984; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992). Similarly, Islamically modified CBT has been used with clients wrestling with anxiety (Azhar, Varma, & Dharap, 1994), depression (Azhar &Varma, 1995b), bereavement (Azhar &Varma, 1995a), and schizophrenia (Wahass & Kent, 1997).
It is noteworthy that, in at least one area (Christian clients with depression), spiritually modified CBT can be considered a "well-established" evidence-based intervention, based on the criteria used by the American Psychological Association's Division 12 Task Force on Promotion and Dissemination of Psychological Procedures (Chambless et al., 1995; Chambless & Ollendick, 2001; Hodge, 2006a). In general, the outcomes obtained with spiritually modified CBT are either similar or superior to the outcomes obtained with traditional CBT (Hodge, 2006a; McCullough, 1999).
The positive findings obtained with diverse problems imply that the effectiveness of spiritually modified CBT is not limited to any single issue. Rather, the favorable results suggest that this approach will also yield positive...