Religiously oriented mindfulness-based cognitive therapy

Religiously Oriented Mindfulness-Based Cognitive Therapy m William Hathaway and Erica Tan Regent University The interface of religiously accommodative and oriented treatments and the cognitive–behavioral tradition is explored. In terms of Hayes’ characterization of the evolution of the cognitive–behavioral tradition through three waves, considerable theoretical, clinical, and empirical work emerged to support a religiously accommodative cognitive– behavioral therapy (CBT) during the second-generation CBTs. Rather than including religion and spirituality, the third-wave CBT traditions have engaged in spiritual themes inspired heavily from Eastern religious traditions. The authors discuss the application of a religiously congruent third-wave cognitive therapy with a depressed conservatively Christian client. Some conceptual challenges and rationales for adopting such treatments with Christian or other theist clients are described. & 2009 Wiley Periodicals, Inc. J Clin Psychol: In Session 65:158–171, 2009. Keywords: mindfulness-based cognitive therapy; religiously congruent therapy; Christianity; religious diversity Introduction There have been longstanding historical tensions between the behavioral tradition and conventional religious worldviews. Often the former has been criticized by religious adherents or sympathizers for being too mechanistic and reductionistic (Van Leeuwen, 1979). At the same time, religion has been conceptualized in a dismissive manner by influential clinicians and psychological scientists. For instance, religion has been construed as a superstitious misappraisal of accidental contingencies and as a breeding ground for maladaptive cognitions such as dogmatism or irrational belief rigidity (Ellis, 2000; Skinner, 1972). Despite this history, there has been a stream within the cognitive–behavioral tradition that has Correspondence concerning this article should be addressed to: William L. Hathaway, Doctoral Program in Clinical Psychology, CRB 161, 1000 Regent University Drive, Virginia Beach, VA, 23464; e-mail: [email protected] JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 65(2), 158--171 (2009) & 2009 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20569 Religiously Oriented MBCT 159 been relatively accommodating to religion and vice-versa (McMinn & Campbell, 2007; Miller, 1988, Pecheur & Edwards, 1984; Propst, 1996; Zhang, 1998). Hayes (2004) has argued that cognitive–behavioral therapy has transitioned through two major waves or generations and currently is undergoing a third major iteration. The first wave of behavior therapy ‘‘yemerged as an approach committed to the development of well-specified and rigorously tested applied technologies based scientifically well-established basic principles’’ (p. 2), particularly those drawn from learning theory. The second generation arrived with the birth of cognitive therapy. Both stimulus-response associationism and behavior analysis had failed to provide an adequate account of human language and cognition, and early behavior therapists soon learned that they needed to deal with thoughts and feelings in a more direct and central way. The cognitive therapy movement attempted to do so. (Hayes, 2004, p. 2) The third wave builds on the earlier behavioral tradition. However, it is typically described by its proponents as more contextual, open to indirect and experiential methods of change, and second-order change goals. Rather than emphasizing changing emotion through cognitive restructuring of the beliefs that mediate those emotions, for instance, the third-wave treatments aim at helping the client foster a different relationship towards troubling emotions that results in a reduction of the suffering associated with them. Most of the research and clinical literature exploring the integration of religious foci or techniques with cognitive-behavioral therapy (CBT) has occurred within the context of the second-generation treatments. One of the clearest examples of these second-generation efforts at accommodating religion and CBT was made by Rebecca Propst (1996) and her colleagues. Propst reported a synergy between CBT’s cognitive change emphasis and religious perspectives. She noted that cognitive change processes are deliberately employed in both Christian spiritual formation and cognitive therapy. In widely cited studies, Propst (1996) designed and implemented clinical trials comparing various aspects of religiously accommodative CBT to standard CBT without the explicit religious accommodations with Christian clients. She reported evidence supportive of the accommodative treatments, whether or not they were conducted by personally religious therapists. In her first study, Propst found that the use of religious imagery condition to be superior with religious patients as opposed to either a nonreligious treatment or wait-list control. All of the therapists for all of the conditions in this study were described as nonreligious. In the second study, Propst and her colleagues used both religious and nonreligious therapists. The religiously accommodative version of the treatment was superior to both the waitlist control and the nonreligious form of the CBT. However, she noted that was true mainly because of a differential impact for the nonreligious therapists. The religious therapists did as well under both forms of therapy with religious clients, but the nonreligious therapists did much better with these clients when they utilized the religiously accommodative protocol. Similar support for religiously accommodative forms of CBT was found in other studies and clinical articles during this second generation period of CBT (Pecheur & Edwards, 1984). In the wake of these early studies and growing recognition of the value religiously accommodated forms of therapy, a burgeoning literature started to emerge providing detailed rationale and guidance for clinicians desiring to Journal of Clinical Psychology DOI: 10.1002/jclp 160 Journal of Clinical Psychology: In Session, February 2009 implement it (Ellis, 2000; Nielsen, Johnson, & Ellis, 2001). In addition to the small but promising empirical literature supporting this development, writers also provided supportive ethical and multicultural rationales for such an endeavor. As Propst (1996) noted, religiously accommodative forms of CBT tended to find ready points of connection with those aspects of religion that have similarly emphasized belief change. Such emphases are longstanding in the Western theisms, but may also be found in other religious traditions (Zhang, 1998). Still, the accommodative forms of CBT emerged as an iteration of standard secular treatments and were primarily instantiated with Christian clients (Tan & Johnson, 2005). The third wave treatments present an interesting contrast to this historical pattern. The mindfulness-based strategies emerged from spiritual and religious soil (Hayes, 2002; Linehan, 1993; Marlatt & Kristeller, 1999). Marlatt and Kristeller (1999) explain, ‘‘to be fully mindful in the present moment is to be aware of the full range of experiences that exist in the here and now. It is bringing one’s complete attention to the present experience on a moment to moment basis’’ (p. 68). Mindfulness is not so much a technique as a particular way of attending that may be fostered by a variety of strategies. These strategies can be found in many cultural contexts, but are highly developed in Eastern spiritual traditions, such as Buddhist Vipassana meditation. Mindfulness-based cognitive therapy (MBCT) extends the mindfulness-based stress reduction approach developed by Jon Kabat-Zinn (1990) at the University of Massachusetts Medical Center for work with stress-related conditions to psychoemotional issues such as depression and anxiety. Mindfulness-based cognitive therapy aims at helping individuals suffering from depression or anxiety disorders to relate to their experience in a new way (Segal, Williams, & Teasdale, 2002). Individuals recovering from depression are taught to experience their thoughts, feelings, and sensations in an accepting manner. Segal et al. (2002) suggested that the approach helps individuals develop a new mode of mind in which they ‘‘yrecognize and disengage from mind states characterized by self-perpetuating patterns of ruminative, negative thoughty. This involves moving from a focus on content to a focus on process, away from cognitive therapy’s emphasis on changing the content of negative thinking, toward attending to the way all experience is processed’’ (p. 75). Mindfulness-based cognitive therapy was designed as a brief, group-based model. The initial evidence for the efficacy for the third-wave treatments is promising, but still possessing significant limitations. Öst (2008) performance of a meta-analysis of third-wave randomized clinical trials drawn from research on acceptance and commitment therapy (Hayes, Strosahl, & Wilson, 1999), dialectical behavior therapy (Linehan, 1993), the cognitive behavioral analysis system of psychotherapy (McCullough, 2000), and integrative behavioral couple therapy (Jacobson & Christensen, 1996) in light criteria for empirically supported treatments. Östst (2008) concluded from the meta-analysis that, moderate effect sizes notwithstanding, none of the third-wave studies had satisfied all of the criteria for an empirically supported treatment. Furthermore, he found that the third-wave studies were less stringent in their design than the supportive research for CBT. Yet Öst chose not to analyze the mindfulness-based research, instead referring his readers to other reviews of the mindfulness-based stress reduction (Kabat-Zinn, 1990) literature and the Segal, Williams, and Teasdale (2002) text. Coelho, Canter, and Ernst (2007) summarized the findings of four studies on MBCT. The findings of the studies reflected an incremental benefit for relapse prevention in patients that have experienced three or more depressive episodes. Journal of Clinical Psychology DOI: 10.1002/jclp Religiously Oriented MBCT 161 Leaving aside the still open issue of the empirical status of the third-wave treatments, how is their work with depression conceptualized? Mindfulness-based cognitive therapy holds that individuals who struggle with recurrent depression tend to have maladaptive thinking styles characteristic of sad moods that are triggered or reactivated by the experience of a sad mood. This is referred to as the ‘‘differential activation hypothesis’’ (Segal et al., 2002, p. 29). Even a small increase in sadness is thought to be capable of reestablishing thinking patterns characteristic of previous depressive episodes. Although a depressive episode may terminate, small increases in an unpleasant mood may be accompanied by large changes in maladaptive thinking patterns. Segal and colleagues also observed that people who tend to be vulnerable to depression are more likely to differ from those who do not in the way that they address the depressed mood. As such, they state, ‘‘ythe task of relapse prevention is to help patients disengage from these ruminative and self-perpetuating modes of mind when they feel sad, or at other times of potential relapse’’ (p. 37). For instance, a client may be able to change their relationship with their negative thoughts or feelings by coming to see them as passing events in the mind instead of as reflections of reality or their true self. Mindfulness-based cognitive therapy refers to this process of seeing one’s thoughts as an event of the mind rather than fact or reality as decentering. By combining mindfulness with other cognitive treatments, clients are taught to increase their awareness of when they are about to encounter a significant mood swing. This awareness would also engage mental resources that would otherwise be used to support rumination. By becoming more mindful, clients could decenter from patterns of depressogenic thinking that are reactivated by sad moods. Some MBCT proponents have claimed that processes like decentering may be what is responsible for the effective change mediation in cognitive therapy rather than change in belief content. In MBCT, clients learn several things: concentration, engaging and maintaining attention on a particular focal point, awareness/mindfulness of thoughts, emotions/feelings, bodily sensations, being in the moment, decentering, acceptance/ nonaversion, nonattachment, kindly awareness, letting go, being versus doing, nongoal attainment, no special state to be achieved, and becoming more aware of how a problem manifests physically. Mindfulness training teaches clients to welcome their experiences, even those that have been troubling, instead of avoiding them. This is done initially by increasing one’s awareness of one’s body and the sensations that it encounters (e.g., tightness of certain muscles when stressed). According to Segal and colleagues (2002), relapse occurs when patterns of maladaptive thinking are reactivated by the experience of sad moods. These patterns are thought to be automatic. As such, mindfulness training increases the client’s ability to have greater awareness of their mode of mind and to disengage from unhelpful modes that perpetuate sadness and depressive thinking. The authors posit that there are two modes of being. The doing/driven mode tends to be triggered when there is a discrepancy between what people wish for or expect and the reality of what is present. In this mode, a person may feel dissatisfied, and tends to focus on the discrepancy, possibly leading to rumination. In contrast, the being mode is characterized by a sense of allowing without the need to expect or to evaluate one’s experience. Thus, the client is able to be in the here and now where the feelings do not trigger automatic modes of doing or thinking that are geared towards changing feelings of dissatisfaction. Journal of Clinical Psychology DOI: 10.1002/jclp 162 Journal of Clinical Psychology: In Session, February 2009 When practicing mindfulness, clients do not try to switch or change thoughts per se, but to change how they relate to them. In other words, thoughts are regarded as events in the mind that are characteristic of the wandering that minds do. Similarly, the goal is to attempt to substitute pleasant for unpleasant emotions. Rather, clients are encouraged to allow their unpleasant emotions to be present. If a client learns to stay present with his or her feelings, despite discomfort, he or she will soon learn that such unpleasant experiences are impermanent. By being mindful, clients learn that they do not have to problem-solve immediately. Yet by remaining in the moment, clients learn that they can take a time-out that permits them to disengage from old patterns of maladaptive thinking. Acceptance is also a key component of mindfulness. As Segal et al. (2002) write, ‘‘An unwillingness to accept negative feelings, physical sensations, or thoughts (due to aversion) is the first link in the mental chain that can rapidly lead to the reinstatement of old, automatic, habitual, relapse-related patterns of mind’’ (p. 223). Thus, the acceptance that ‘‘thoughts are not facts’’ leads clients to experience a distance from the unpleasant emotions (p. 256). Clients who are educated in MBCT learn to develop an action plan to prevent relapse of depressive symptoms over the course of treatment. This action plan consists of three phases: (a) take a breathing space and decenter from unpleasant emotions and maladaptive thoughts, (b) choose a practice that is helpful for grounding the person in the present, and (c) take action that gives a sense of pleasure or mastery and break the activity down into smaller parts. The Case of Ruby Presenting Problem Ruby is a married 32-year-old Caucasian female with three children living in the Midwest. She presented in therapy with flattened affect, stating that she was struggling with feelings of depression, anxiety, irritability, and difficulty focusing. She was also exhibiting self-reproach for yelling and ‘‘snapping’’ at her preadolescent son of 8 and her two preschool children, ages 2 and 2. At the time she initiated psychotherapy, Ruby was going through a very rigorous program associated with Overeaters Anonymous (OA), but had not previously received psychotherapy services. Ruby and her husband were married for 11 years when she came in for therapy. In the winter of the prior year, Ruby’s husband disclosed that he had a couple affairs since they had been together. One occurred before their marriage, and the other happened during their marriage. At the time she entered therapy, Ruby stated that she was not feeling resentful towards her husband because he went through a paraprofessional recovery ministry to deal with his infidelities. She had gone through a grieving period at the time he disclosed the affairs but stated that she felt better after about 3 weeks. At the time of the intake, she stated that she felt as though she had dealt with the affairs adequately. Ruby was following a food program with OA to address her obesity. She described herself as engaging in ‘‘compulsive overeating’’ particularly when she felt ‘‘emotional.’’ She stated that she was aware of this pattern at least since she was 9 or 10 years old. She recalled that being a difficult time in her life because her biological father was very angry and she witnessed him physically abusing her mother. There was a lot of yelling in the home, and he would often force people to stay at the dinner table. After his outbursts, he would sometimes typically try to make amends with Journal of Clinical Psychology DOI: 10.1002/jclp Religiously Oriented MBCT 163 food by taking the family out to eat or bringing food home. Ruby’s parents moved shortly after this period and she stated that, for whatever reason, things improved at home. However, she recalls having trouble adjusting to the move and remembered feeling depressed for a few years after it. In middle school, Ruby disclosed that she stopped eating, engaged in anorexia-type behaviors, and would lie to her parents about eating. She began abusing laxatives around age 15 and started smoking and consuming caffeine. In addition, she also began to engage in self-harm with cutting to relieve her emotional pain. At the time of the diagnostic interview, Ruby also expressed concern about her expected weight loss if she were successful in her weight management efforts, worrying that her sexuality would become more sensual with the decrease in weight. In the past, she stated that she had used her sexuality to ‘‘manipulate men.’’ She was also concerned that the weight loss would make her husband feel insecure in their marriage. Ruby self-reported that her mood was depressed and anxious and intensified around the time of her menstrual cycle. Her physician felt that she had premenstrual dysphoric disorder in addition to a more chronic depression. She reported that her first bout of depression occurred when she was 13 years old. In the past, she had entertained thoughts of suicide, but denied those at present. She believes that both of her parents experienced depression. In addition, her mother was reported to struggle with an eating problem. Ruby stated that her mother was anorexic previously, but was now overeating. Aside from smoking cigarettes consistently between the ages of 12 and 21, Ruby smoked marijuana five times in college. She abused alcohol in high school during her senior year to escape and feel better about herself. However, her grandfather was reported to struggle with alcoholism. Ruby mentioned that she and her family were members of a local church and were regular attendees. Her parents brought her and her siblings to church regularly after they moved to the state when she was 8 or 9 years old. Ruby stated that she wanted to address her spiritual concerns in treatment because she wanted to ‘‘be held spiritually accountable according to what God’s word says in the Bible.’’ She also indicated that she sought out a Christian practice because she thought it would be conducive to this goal. She described God as ‘‘love, trust, and security,’’ and believed that God saw her as ‘‘fallen and baby-stepping’’ in her efforts to get better. Although Ruby felt that her relationship with God was better than it had ever been at the time of the initial session, she felt that it could be better. Case Conceptualization Ruby’s symptoms included recurrent feelings of depression and anxiety, changes in sleep, irritability, difficulty concentrating, emotional lability, interpersonal problems, and maladaptive thoughts that perpetuated feelings of guilt and shame. At intake, Ruby met the diagnosis for major depressive disorder, recurrent with moderate severity, at the time of her initial treatment session. Ruby also reported that she had trouble dealing with these unpleasant feelings in a constructive manner. When the negative feelings increased, she would perform various avoidance strategies to seek relief. These strategies often involved unhealthy patterns such as compulsive eating. After engaging in these avoidance or distraction coping activities, Ruby relayed compounded negative affect from the realization that she had wasted her time and made matters worse. Yet, despite a fair aptitude at self-description, she did not seem Journal of Clinical Psychology DOI: 10.1002/jclp 164 Journal of Clinical Psychology: In Session, February 2009 to have clear insight into how this unpleasant emotions - avoidance coping unpleasant emotions pattern represented a vicious maladaptive cycle. Her depression also worsened during major life changes (i.e., childhood move, postpartum, marital changes). The combination of unipolar depression, self-perpetuating avoidance coping cycles, and motivation to reflectively face her difficulties in treatment, suggested that she may benefit from cognitive therapy incorporating mindfulness and acceptance treatments. Ruby also relayed problems with intimate relationships that seemed to be connected to her avoidance pattern. Her scarce friendships and difficulty feeling close to her husband in her marriage both appeared related to beliefs she held about her own lack of self-worth and the untrustworthy nature of other people. This set of beliefs was further complicated by her recurrent feelings that God was displeased with her for her numerous life failures. When Ruby felt tension or discomfort in her relationships, and this was often, she would hold her feelings in, withdraw from contact, and intensify her overeating. Rather than turning to an inward faith by seeking comfort from God in such moments, she would also feel that God was someone to avoid. Consistent with a cognitive therapy framework, Ruby’s depressogenic cognitions were viewed as fueling her negative and depressive emotional responses to life. Furthermore, her maladaptive coping mechanisms aimed at producing relief from these negative feelings seemed to exacerbate the problems. She would eat to find release from negative feelings. This would, in turn, result in her having even more negative feelings about her weight gain, prompting further compulsive eating. She would feel badly about not feeling closer to her husband sexually or emotionally, but also felt some conflict over losing weight because the weight seemed to protect her from intimacy to some extent. Some proponents of the third-wave treatments have suggested that they are building on the true core change process in CBT and that this process is not due to change in specific belief content as much as learning to relate to those beliefs differently. Hayes et al. (2007) state that Mindfulness-based cognitive therapyyreduces relapse by teaching participants to move into rather than away from negative emotions and to use acceptance-based strategies to engage but not become entangled in the disturbing material. These therapies for depression can be construed as applying some principles of exposure to reduce avoidance and increase the flow of new and corrective information. (p. 411) In light of the third-wave treatments, much of her energy was aimed at unsuccessfully avoiding or eradicating negative emotional states. Consequently, when she began to feel badly she would eat, ruminate about all of the failures or negative things that would justify the feeling, mull over what she might have done to displease God, or otherwise remain consumed by depressive frames of mind. During these states, she concluded that this is just the way she is and doubted that things would change. A treatment plan was thus formulated that would address both the content and process of her thinking that was resulting in her suffering. Furthermore, the client’s spontaneous and explicit mention of religious themes in a faith-affiliated practice context that she sought out of her volition indicated that a religiously congruent cognitive approach may be appropriate. Ruby would be seen for individual therapy Journal of Clinical Psychology DOI: 10.1002/jclp Religiously Oriented MBCT 165 over 18 weeks. Aspects of traditional CBT and MBCT would be combined in this treatment. Mindfulness-based cognitive therapy is usually run in a group setting that follows an 8-week term. Because no such groups were available in her area when Ruby entered treatment, the principles of MBCT were extricated and applied in individual therapy. Course of Treatment After the diagnostic interview, Ruby presented in the second session with a depressed mood, stating that she had had ‘‘bad’’ days for the majority of the time since the first session; however, she did observe that she had one ‘‘good’’ day. During this first postintake session, Ruby was also given an overview of the proposed treatment. The mediating role of cognitions in shaping the emotional experiences that result from life situations was explained. The basic features of the mindfulness-based treatments were also described as a way to help her alter her counterproductive avoidance coping that may have been helping to maintain her negative emotions. Ruby appeared to accept the framework without reservation or concern. The balance of the session focused on two behavioral CBT components. She was educated on the use of constructive distraction techniques that might facilitate healthy goal attainment, such as exercising, and pleasurable activity scheduling. During the session, Ruby expressed self-contempt and indicated that she was a weak Christian who must be a disappointment to God. She felt as though He was judging her because she was not ‘‘doing well’’ with eating or her interactions with her husband. She indicated that she believed she must be a ‘‘failure’’ in God’s eyes. In the following session, Ruby reported some increase in her participation in pleasurable activities, such as crocheting. Although she noted some slight improvement in her mood, she felt more irritable and frustrated with her husband. The second session focused on teaching Ruby about mindfulness. She was given instructions to increase mindfulness by becoming more aware of her bodily sensations, focusing on breathing as an anchor for her attention and concentration. The use of breathing as a focal point is important for several reasons: (a) it is something that a person always has to do, so it is always available; (b) it is an act of being in the sense that the person just breathes without striving to do anything else; and (c) it helps to create distance from the immediacy of unpleasant emotions or maladaptive thoughts thus decentering the person from the desire to change his or her present circumstance. Ruby was also taught the principle of acceptance of any situation she encountered. Although she does not have to like what is occurring in the moment (e.g., conflict with her husband), it is helpful to accept that ‘‘it is what it is’’ so that she can become less judgmental of herself, her husband, their relationship, their thoughts, and their feelings. In the practice of nonjudgment, a person learns that a situation is neither ‘‘good’’ nor ‘‘bad,’’ it just ‘‘is.’’ Nonjudgment and acceptance were essential skills for Ruby to acquire to decreased conflict with her husband because of her tendency to blame him, as well as her propensity for experiencing shame and guilt. Ruby presented with brighter affect and a more positive mood in both the fourth and fifth sessions. In the practice of mindful breathing, she had become more aware of her thoughts and emotions. She also practiced nonjudgment and acceptance with her husband, which served to decrease the intensity and frequency of conflict. In these sessions, the practice of mindfulness, acceptance, and nonjudgment were reinforced and discussed in further detail. Journal of Clinical Psychology DOI: 10.1002/jclp 166 Journal of Clinical Psychology: In Session, February 2009 Ruby had not voiced any religious concerns about the mindfulness treatment previously, but she did raise some questions about how to understand this approach from a Christian point of view. The therapist explored with Ruby how she herself might make sense of it, given her personal religious beliefs. Ruby acknowledged that her belief in grace and God’s unconditional love meant that God accepts her as she is. However, she stated that she was beginning to realize that she often did not remember God’s love for her in her daily life. By the end of the session, Ruby seemed to realize that by spending so much time either running from the unpleasant feelings and experiences or by hyperfocusing on them to the exclusion of other experiences, she was left with little or no concrete awareness of God’s grace in her life. By becoming more open to the reality of her own experiences, Ruby was encouraged to see her own life the way God sees it from a perspective of grace. The therapist was not telling Ruby what she should believe about God, grace, or any theological notion. Instead, the therapist unpacked the significance of a belief about God that Ruby already endorsed and helped her to sort out the helpful psychological implications of that belief that had not yet been realized in the client’s experiences. This mild cognitive disputation paved the way for her to embrace the mindfulness strategies more fully. Ruby reported feelings of relief from practicing nonjudgment toward her own experiences. She also observed that she found it to be slightly easier to extend grace to others. She claimed to be more aware that God’s grace was unrelenting despite her behaviors, experiences, or feelings. As such, if she could accept God’s grace for her, she would be more capable of extending it to her husband and children. Although Ruby was experiencing a positive mood more frequently, she observed that she was feeling more anxious and depressed than she had in the previous 2 weeks. At its worse, Ruby reported that she had feelings of ‘‘paranoia’’ pertaining to her ability to parent, her weight, her experience of depression, and her marriage. Over the course of the sixth, seventh, and eighth sessions, therapy tended to focus on increasing mindfulness and acceptance of these feelings for the purpose of decentering from ‘‘paranoid’’ thoughts and unpleasant emotions. By distancing herself from the intensity of these thoughts and feelings, Ruby seemed able to realize that these thoughts ‘‘were just thoughts’’ as opposed to ‘‘facts.’’ A dramatic decrease in anxiety was observed on her subjective self-rating and reported levels of physical tension throughout her body. Ruby also noted that she was less prone to emotional eating when she was able to engage in mindfulness regarding these distressing thoughts and feelings. At this point in the therapy, Ruby was encouraged to be mindful of ‘‘inviting’’ God into dialogue with her about the distressing thoughts and feelings she had, particularly as they related to overeating and the subsequent guilt and shame she felt after engaging in that behavior. This was accomplished by a simple instruction to meditate on God’s presence as she was engaging in the mindfulness activity and to communicate with God during that time. As Ruby became more willing to be honest and open in her relationship with God about her eating and undesirable behaviors, such as irritability with her husband and children, she reported that she experienced greater intimacy and stability with Him. At times, she began to relish the conversations that they were sharing about the ins and outs of her day. She relayed becoming more able to take the ‘‘good’’ and the ‘‘bad’’ experiences in stride together without allowing a desire to eliminate negative feelings or experiences to consume her throughout the day. Ruby’s negative mood, both in terms of anxiety and depression, decreased dramatically by the ninth session. She also relayed experiencing a more consistent Journal of Clinical Psychology DOI: 10.1002/jclp Religiously Oriented MBCT 167 positive mood. Although she was becoming more proficient in utilizing mindfulness to become less judgmental and more accepting of her husband and her children’s behaviors, she was still sporadically engaging in judgmental thoughts towards her own feelings. For example, if she found herself overeating, she would continue to feel guilty and ashamed for a period. By applying nonjudgment and acceptance of her feelings and thoughts, Ruby learned that she was not just a ‘‘failure’’ if she was overeating because she had become more mindful in the moment that she was eating emotionally. Gradually, as Ruby began to become more aware of her emotions, she began to realize that she was more likely to overeat when she felt anxious, sad, or frustrated. By accepting these feelings without judging them, Ruby was able to identify other behaviors that she could engage in, such as crocheting, playing with her children, or reading to self-soothe so that she did not act out of those feelings. Ruby also reported that as she became more comfortable with these unpleasant emotions, she was only infrequently feeling the pressure to do something to avoid the negative feelings when they did arise. She also relayed that this allowed her to feel more connected with her husband as she was not allowing momentary tensions in their relationship to drive her away from intimacy. By being more present in the moments they shared together, she also relayed feeling closer to him emotionally and physically. This increase in acceptance and nonjudgment in her relationship with her husband also appeared to facilitate what she described as ‘‘better spiritual synchrony’’ in their marriage. She felt as though she could trust him more with their marriage, as well as decisions he was making for the betterment of their family (e.g., his job). Ruby and her husband became more intentional about pursuing a joint relationship with God. They began to complete devotions together and prayed more frequently together. Ruby’s mood had stabilized and her interactions with family members became less irritable and agitated as her proficiency in mindfulness, acceptance, and nonjudgment developed. She began to engage in more activities that increased positive mood and noticed that it was not as difficult as it had been in the past to come up with an idea for an activity that would preoccupy her mind instead of ruminating about things that made her feel sad or anxious. This change in her approach to her thoughts also gave Ruby room to begin using more conventional CBT modalities of treatment, such as the dysfunctional thought record or the process of finding evidence against thoughts that would have previously been accompanied by an unpleasant mood. Ruby was taught to use prayer and Scripture as a means of finding evidence that did not support her self-defeating thoughts about her (e.g., ‘‘I will never changey I will always be depressed’’), her family members (e.g., ‘‘My husband will always be this way’’), her family life (e.g., ‘‘We’ll always be stuck here in the city instead of the country’’), other people (e.g., ‘‘People are always out to get me’’), and her relationship with God (e.g., ‘‘He doesn’t like me’’). Ruby became more excited about finding passages of Scripture to hold onto or internalize as promises to refute the maladaptive thoughts. By becoming more mindful of these maladaptive thoughts, Ruby demonstrated proficiency in minimizing the frequency with which she experienced a sad or anxious mood. Thus, she was able to disrupt the downward spiral that she would have fallen into if she had continued to simmer in the sad or anxious feelings and the accompanying thoughts that would have been triggered. Ruby was able to acknowledge that her feelings and thoughts were ‘‘just’’ feelings and thoughts that she was experiencing in the moment and that they would pass without necessary action. Journal of Clinical Psychology DOI: 10.1002/jclp 168 Journal of Clinical Psychology: In Session, February 2009 In addition, Ruby’s willingness to practice acceptance and nonjudgment facilitated a more intimate relationship with God that was characterized by honesty and openness because she was able to grasp the concept of grace more fully. In addition, she was able to extend grace more effectively to her husband and children. By understanding and taking hold of God’s grace for her, Ruby’s perception of God changed from feeling as though He demanded perfection to believing that He was able to meet her in times of weakness and brokenness without punishment. The depth of this change in her perspective of God was evident in the lack of selfcondemnation she felt when she did engage in periodic emotional eating, or if she and her husband had a conflict. However, over the course of therapy, the frequency of these behaviors diminished, as did her feelings of depression, anxiety, and irritability. Ruby initiated terminating her therapy by asking to be seen only once every couple of months for ‘‘booster’’ sessions because she was no longer experiencing overwhelming thoughts and feelings of sadness, anxiety, and irritability. She was encouraged to increase her effectiveness with self-care. In other words, Ruby was now at the point where she was able to manage her feelings and thoughts mindfully without adverse consequence. She was encouraged to build mastery by engaging in activities that she found challenging, requiring her to step outside of her comfort zones for self-soothing. Ruby realized that she no longer needed or wanted the intensive program associated with OA to manage her eating habits. She was now able to eat for the purpose of hunger and to refrain from eating as a self-soothing technique for other emotional reasons. In place of compulsive eating during such times, she was now able to enter into conversations with God about these feelings and drew comfort and a sense of peace from this activity. Outcome of Treatment At the beginning of therapy, Ruby’s adaptive functioning was rated with a global assessment of functioning (GAF) score of 55, indicating that she was experiencing significant difficulty in her home life and relationships. In the last few sessions leading up to planned termination, Ruby experienced life without the intense periods of sadness, irritability, overeating, and conflict in her relationships that had been more typical prior to treatment. Her GAF score at termination was noted as 80. The client was asked to generate a subjective unit of distress (SUD) rating for feelings of anxiety, depression, and hopelessness each week over the course of treatment. At intake, she rated her anxiety and depression at an 80 and hopelessness at a 60 on a 100-point SUD scale with 100 meaning ‘‘most intense ever.’’ By the end of treatment, Ruby’s SUD ratings had reduced to 5 for depression, 10 for anxiety, and 1 for hopelessness. In terms of her spiritual life, Ruby reported feeling closer with God. She also stated that she was able to be in God’s presence without the feelings of shame or guilt she had previously felt. She attributed this to her greater realization of what grace means and her deepening knowledge of His acceptance of her. Clinical Issues and Summary The case of Ruby illustrates many of the common issues that arise in what has been variously termed religiously sensitive, religiously accommodative, or spiritually oriented cognitive therapy. Yet it also represents an extension of this form of CBT into the third-generation treatments with a relatively conventionally religious Journal of Clinical Psychology DOI: 10.1002/jclp Religiously Oriented MBCT 169 Christian client. In line with Ellis’s (2000) acknowledgement that some religious beliefs can be harnessed for the good of the client, the amplification of the notion of grace emic to Ruby’s religious worldview paved the way for her adoption of a mindfulness-based approach to her difficulties. Although much of the course of treatment relied predominantly on MBCT, elements of more classic CBT also played an important role. For instance, the Christian client’s acceptance of the mindfulnessbased approach was supported by a religiously congruent cognitive disputation. The client’s professed belief in, and understanding of, divine grace did not fit with her own experience and cognitive habits. By helping the client face this incongruence, she was able to develop less depressive self-repeating modes of thinking. The third-wave cognitive–behavioral treatments would be a natural fit to many practitioners of Eastern religious traditions because they rely on meditative practices and coping styles that are long-lived in those traditions. Yet as Marlatt and Kristeller (1999) have noted The meditation techniques that have gained the most attention within clinical practice in the United States in the past several decades have come from the Eastern traditionsy. Hence, there is sometimes confusion or concern that meditation practices are in some way antithetical to Western or Christian religious or spiritual practice and belief. (p. 68) In Ruby’s case, a relatively low-level religiously congruent disputation seemed to free up the client to explore the value of mindfulness-based treatments. However, it is possible that some clients from the Western theistic traditions may display a greater resistance to such treatments similar to the conservative Christian reaction to hypnotherapy, yoga, or other forms of meditation that were associated with the advent of the ‘‘new age movement.’’ Fortunately, a number of productive theological resources exist to aide in forging a respectful response to such religiously based discomfort with the third-wave strategies. Tweed (1997) and Highland (2005) provide two examples of such resources. Both of these theology articles provide rich accounts of the influential Christian theologians, Gregory and Augustine, who articulated a meditative spirituality with many parallels to mindfulness. The challenge is to find clinically useful ways of harvesting such sophisticated theological and philosophical reflections. Although a professional respect for religious diversity and client autonomy may require us to refrain from certain treatments, the interesting history of religion in rational-emotive behavior therapy (REBT) suggests constructive rapprochement between the newer generation cognitive therapies and conservatively religious Western worldviews may not be surprising. Still, a richer set of theistic theological categories and descriptors need to be harnessed by the third-wave proponents who want to promote their wares to a still predominantly theistic Western religious consciousness. Tan (2007) has recently made some contributions in this regard. He points out that theistic notions such as de Caussade’s (1861/1989) sacrament of the present moment provide some support for the embrace of contemplative or meditative treatments. In Tan’s approach, self-designated as Christian CBT, he incorporates an ‘‘inner healing strategy,’’ along with other religiously accommodative CBT treatments. This strategy involves a prayerful request for the Lord to ‘‘y come and minister to the client His comfort, love and healing gracey.’’ (Tan, 2007, p. 104). Tan further explains that ‘‘the emphasis here is to be open, receptive and accepting toward what Journal of Clinical Psychology DOI: 10.1002/jclp 170 Journal of Clinical Psychology: In Session, February 2009 the Lord wants to do, and therefore to be more contemplative in prayer before Him’’ (p. 104). The client is directed to attend to their current experience with this open attitude as he or she goes through the contemplative exercise. The third-wave treatments continue the behavioral tradition’s emphasis on evidence-based practice. Such religiously accommodative treatments of the thirdwave therapies may yet suffer from the liability of ‘‘getting ahead of the data’’ (Corrigan, 2001). However, consideration of client values constitutes one of the foundational domains in the evidence-based practice tradition. In the absence of evidence of iatrogenic effects, there are good ethical/multicultural basis for such efforts. Assuming the promising research to date delivers a verdict of adequate support to the third wave, the next challenge will be for dismantling research to tease out the active ingredients in these treatments. Such research would highlight the specific areas where bridge phrases and concepts need to be promulgated to aide therapists in making contextually sensitive and effective novel applications of these strategies drawn from ancient and venerable soil. References Coelho, H.F., Canter, P.H., & Ernst, E. (2007). Mindfulness-based cognitive therapy: Evaluating evidence and informing future research. Journal of Consulting and Clinical Psychology, 75, 1000–1005. Corrigan, P.W. (2001). Getting ahead of the data: A threat to some behavior therapies. The Behavior Therapist, 24, 189–193. de Caussade, J.P. (1989). The sacrament of the present moment (K. Muggeridge, Trans.). 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