Psychotherapy

Enhancing the Evidence Base for Spiritually Integrated Psychotherapies:

Progressing the Paradigm of Practice-Based Evidence
P. Scott Richards and Michael Barkham
Online First Publication, August 1, 2022. http://dx.doi.org/10.1037/pst0000438

CITATION
Richards, P. S., & Barkham, M. (2022, August 1). Enhancing the Evidence Base for Spiritually Integrated Psychotherapies:
Progressing the Paradigm of Practice-Based Evidence. Psychotherapy. Advance online publication.
http://dx.doi.org/10.1037/pst0000438
 Psychotherapy
© 2022 American Psychological Association
ISSN: 0033-3204 https://doi.org/10.1037/pst0000438

INTRODUCTION

Enhancing the Evidence Base for Spiritually Integrated Psychotherapies:

Progressing the Paradigm of Practice-Based Evidence
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P. Scott Richards1 and Michael Barkham2

1
Bridges Institute for Spiritually Integrated Psychotherapies, Saint George, Utah, United States
2
Clinical and Applied Psychology Unit, Department of Psychology, University of Sheffield
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Spiritually integrated approaches to psychological therapies enable practitioners to be responsive to clients’

religious and spiritual concerns and have been combined with most mainstream therapeutic approaches. As
such, although evidence is required regarding their efficacy, with randomized controlled trials having a
privileged status, a single research paradigm is unlikely to deliver both a robust and relevant evidence base for
the psychological therapies, that is, embedded in routine practice. The research paradigm of practice-based
evidence provides a complementary approach to trials methodology as carried out in routine practice via the
application of a myriad of qualitative and quantitative research designs. Accordingly, this article provides the
background to a special section comprising 12 articles within a practice-based evidence paradigm that captures
a focus on the therapist, the content of sessions and therapist–patient interactions, applications to specific
patient populations and therapy modality, and the outcomes of spiritually integrated psychological therapies.

Clinical Impact Statement

The R/S studies highlighted in this special section identify key interventions for the advancement of
spiritually integrated psychotherapies.

Keywords: spirituality, psychotherapy outcomes, psychotherapy processes

The growth of a more culturally and spiritually open zeitgeist in
the behavioral sciences has made space for the development and
adoption of spiritually integrative psychotherapy approaches
(Worthington, 2011). Spiritually integrative approaches encourage
clinicians to address clients’ religious and spiritual concerns, if
relevant to treatment, and to use language and interventions that
show respect for and access the healing resources of their clients’
faith. In the APA Handbook of Psychology, Religion, and Spiritu-
ality, Sperry (2013) provided a helpful definition of spiritually
integrative therapy stating that it “ : : : draws on spiritual resources
in addressing spiritual issues and struggles to resolve psychological
and relational problems. Although it can also foster spiritual change
and growth, spiritually integrated psychotherapy accomplishes this
as a by-product that accompanies psychological change” (p. 227).
As such, spiritually integrative psychotherapy approaches have been
combined with most mainstream therapeutic traditions, including
cognitive–behavioral, gestalt, interpersonal, humanistic, Jungian,
multicultural, multicultural, psychodynamic, rational-emotive, and
transpersonal approaches (Richards & Bergin, 2005, 2014; Sperry &
Shafranske, 2005). They have also been used with a variety of client
populations and clinical issues. Such approaches have been used
with adherents to most of the major world religions, including
Buddhism, Christianity, Islam, and Judaism (Richards & Bergin,
2014; Richards et al., in press; Sperry & Shafranske, 2005).
Outcome research concerning the efficacy and effectiveness of
spiritually integrative treatment approaches has increased during the
past three decades as exemplified by successive meta-analyses.
Worthington et al. (1996) reported only eight outcome studies from
a pool of 148 empirical studies on religion and psychotherapy, while
McCullough (1999) meta-analysis comprised five outcome studies,
and Worthington and Sandage (2001) carried out a narrative review of
nine outcome studies. Subsequent meta-analyses and systematic

P. Scott Richards played lead role in funding acquisition, project

P. Scott Richards https://orcid.org/0000-0003-3189-2358
The authors’ work on this article and this special section of Psychotherapy
was supported in part by grant #60877 (Enhancing Practice-Based Evidence
for Spiritually Integrated Psychotherapies: An Interdisciplinary Big Data
Project) awarded to the first author by the John Templeton Foundation.
Michael Barkham was a developer of of the CORE-10 outcome measure
that was used in a number of articles published in this special section but
receives no financial gain from its use.
administration and writing of original draft, supporting role in writing
of review and editing and equal role in conceptualization. Michael Bark-
ham played lead role in writing of review and editing and equal role in
conceptualization.
Correspondence concerning this article should be addressed to P. Scott
Richards, Bridges Institute for Spiritually Integrated Psychotherapies,
5259 N. Hidden Pinyon Drive, Saint George, UT 84770, United States.
Email: pscottrichards@gmail.com

1
 2 RICHARDS AND BARKHAM
reviews revealed a substantial increase in the number of studies: Smith
et al. (2007) meta-analyzed 31 outcome studies, Hook et al. (2010)
carried out a narrative review of 24 studies examining which spiritually
integrated psychotherapies meet evidence-based criteria for efficacy
and specificity, and Worthington et al. (2011) meta-analysed 61
outcome studies. Most recently, Captari et al. (2018) conducted a
meta-analysis of 97 outcome studies of spiritually integrated psy-
chotherapies and reported significant effect sizes for psychological and
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spiritual outcomes compared with no-treatment controls of .74 for both
outcomes, .33 (psychological) and .43 (spiritual) for comparative
designs, and .34 (spiritual) for additive designs. Overall, the body
of meta-analytic and narrative reviews of the outcome research have
shown that spiritually integrated approaches are often as effective as
secular ones, especially with religiously devout clients (Richards &
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Worthington, 2010) and that evidence suggests that unsurprisingly,
spiritually integrated psychotherapies result in greater spiritual
improvement than do standard secular treatments (Captari et al., 2018).
However, conclusions about the efficacy and effectiveness of
spiritual approaches must be tempered by the fact that many of the
data-based outcome studies have significant methodological weak-
nesses (Anderson et al., 2015; Smith et al., 2007; Worthington et al.,
2011). As is the case with all trials in the field of the psychological
therapies where either a comparison between two active treatments
or an investigation into the contribution of an additive component
(wherein the two therapies are otherwise the same), the expected
differential effect size will inevitably be small and hence the
required sample size will be large (see Barkham & Lambert,
2021; Cuijpers, 2016). Accordingly, while the methodology of
trials is rigorous and crucial for securing a robust evidence base,
the demands for securing funding are considerable, as are the
requirements for conducting such trials. Moreover, many practi-
tioners working in routine practice are disenfranchised from con-
tributing to such trials and evidence suggests that clients from
culturally diverse backgrounds are underrepresented in trials,
although there is some evidence that the situation is improving
(e.g., Polo et al., 2019).
Notwithstanding the current evidence for the use of spiritually
integrated psychotherapies in mainstream clinical practice, we
consider there to be at least two challenges that need to be addressed
in future research. The first challenge is that despite the growth in the
evidence base, it is still the case that many spiritually integrative
treatment approaches have not been empirically evaluated (Richards
et al., in press). We think it is essential for those who incorporate
spirituality into treatment to conduct and publish process and
treatment outcome studies about their approaches (APA
Presidential Task Force on Evidence-Based Practice, 2006;
Richards et al., 2015). And there are reasons to believe this may
already be happening. An unpublished review of the literature about
spiritually integrated treatment approaches located nearly 300 arti-
cles examining the efficacy and effectiveness of spiritually inte-
grated treatment approaches (Jackson et al., 2019), and a search of a
mainstream library database revealed a curvilinear increase in this
literature, as more researchers and practitioners have developed and
conducted studies across many theoretical orientations, client po-
pulations, clinical issues, and spiritual traditions. In addition, the
review revealed that efficacy studies still dominate this area of
psychotherapy research (Jackson et al., 2019).
A second major challenge is that more information is needed
about how practitioners incorporate spirituality into their clinical
practices. Although randomized controlled trials, and other forms
of experimental studies, are valuable for establishing the efficacy
of therapeutic approaches, they usually give little insight into how
psychotherapists implement spiritually integrative approaches in
routine practice. We need more insight into the following types of
questions: How do practitioners go about integrating spiritual
perspectives and interventions with mainstream therapeutic ap-
proaches? What spiritual interventions do psychotherapists use
during treatment and how often do they use them? What spiritual
interventions and approaches are most effective for different types
of clients, clinical issues, and treatment settings? What types of
spiritually integrative treatment processes are predictive of posi-
tive treatment outcomes? More insight into such questions would
help us better understand what the best practices are for the
integration of spirituality into routine clinical practice (Richards
et al., 2015).
There is growing awareness that there is no universal best
method for developing an evidence base in the field of psycho-
therapy and that multiple research designs are needed to develop an
evidence base for everyday practice (APA Presidential Task Force
on Evidence-Based Practice, 2006; Barkham et al., 2010). Indeed,
it seems unlikely that a single research paradigm can deliver both a
robust and relevant evidence base of the psychological therapies.
Although we endorse the need for additional experimental out-
come studies and for the improved rigor of these studies, we accept
a broad criterion for what constitutes empirical support or
evidence-based treatment. We agree with the APA’s 2005 Policy
Statement on Evidence-Based Practice in Psychology (APA
Presidential Task Force on Evidence-Based Practice, 2006), which
encourages “the integration of the best available research with
clinical expertise in the context of patient characteristics, culture,
and preferences” (p. 284). The APA Task Force report also states:
“Best research evidence refers to scientific results related to
intervention strategies, assessment, clinical problems, and patient
populations in laboratory and field settings as well as to clinically
relevant results of basic research in psychology and related fields”
(p. 274). The report also lists and briefly describes a variety of
research designs and how they may contribute to evidence-based
practice, including individual case studies, qualitative research,
systematic case studies, single-case experimental designs, public
health and ethnographic research, process-outcome studies, stud-
ies of interventions in naturalistic settings, randomized clinical
trials (RCTs), and meta-analyses.
Within the scope of approaches set out by the APA Task Force,
we consider practice-based evidence designs to be especially well-
suited for enriching the evidence base about the psychological
therapies, including spiritually integrated psychotherapies
(Barkham et al., 2010; Richards et al., 2015). Such a research
paradigm has emerged as a complement to trials-based methodolo-
gies and, because it is generated by practitioners and patients from
the bottom up (i.e., rooted in everyday practice), it has the potential
to be self-sustaining whereby psychological therapy clinics and
services take responsibility for collecting data and generating data-
informed interventions relevant to their own specific localities. And
the failure to utilize data that are collected in routine practice led
Kazdin (2008) to state: “We are letting knowledge from practice drip
through the holes of a colander” (p. 155). Such a paradigm allows
for organic collaboration across smaller localities to build larger
datasets through the adoption of common core outcome, or process,
 SPIRITUALLY INTEGRATED PSYCHOTHERAPIES
measures. Such activities can often be partially formalized as
practice research networks (see Barkham, 2014; Castonguay et
al., 2010). They can also generate communities of practice, a less
formalized and more organic concept (Wenger, 1998).
The arguments for promoting practice-based evidence have been
made on multiple occasions (e.g., Barkham & Mellor-Clark, 2003;
Barkham & Margison, 2007; Barkham et al., 2010), and the
accumulated evidence arising from this paradigm has been reported
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in successive editions of Bergin and Garfield’s Handbook of
Psychotherapy and Behavior Change (see Castonguay et al.,
2013, 2021). Returning to Kazdin’s (2008) colander analogy,
data from routine practice can be obtained for every patient at every
session receiving any form of psychological therapy or intervention
delivered by every therapist or practitioner in every clinic or
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psychological service. This is the potential and the prize of
practice-based evidence. Such an accumulated database would
have unlimited potential for delivering data-informed assignments
of patients to treatment and therapist, to monitor progress, and
provide feedback to therapists to adapt therapy as required (see Lutz
et al., 2022).
In keeping with a methodologically pluralistic approach to devel-
oping an evidence base, in this special issue of Psychotherapy, we
invited researchers to submit a broad range of data-based studies,
including qualitative, quantitative, and meta-analytic studies that
examined the role of religion and spirituality in the psychological
therapies. The first article (Captari et al., 2021) provides a valuable
synthesizing of the literature regarding real-world evidence of
spiritually integrated psychotherapies. The next two articles present
qualitative studies focusing on the key role of therapists, first in
Buddhist-informed compassion training (Quaglia et al., 2021) and
then in relation to therapist mindfulness (Konichezky et al., 2021).
The next three articles focus on the process of therapy sessions, the
first adopting a mixed-methods design to study therapist–client
synchrony (Roesler & Reefschläger, 2021), the second also using
a mixed-methods approach to analyze microagressions (Trusty et
al., 2021), while the third article applies task analysis to video-
recordings of therapy sessions (Kim & Chen, 2021). This is
followed by two articles, the first addressing a specific patient
population (i.e., inpatient, residential, and intensive treatments;
Rosmarin et al., 2021) and the second focusing on a specific therapy
modality (i.e., couple therapy; Ripley et al., 2021). The next two
articles move to considering outcomes, first in relation to patient
preferences (Swift et al., 2021), and second by integrating religion
and spirituality into Gestalt therapy (Thomas et al., 2022). The final
two articles apply multilevel modeling, first to data from Sufi
psychotherapy practice (Bozorgzadeh & Grasser, 2021), and second
to a cross-cultural dataset examining the processes and outcomes of
spiritually integrated psychotherapies (Sim et al., 2021).
In conclusion, we are pleased to see these 12 manuscripts,
representing a variety of research methodologies and spiritually
integrated approaches, published in this special issue of Psycho-
therapy. We think the articles provide rich insights into how
spiritually integrated psychotherapies may be implemented in prac-
tice and their potential for enhancing the processes and outcomes of
psychological treatment. We hope this special issue will inspire
researchers and practitioners from diverse spiritual traditions and
theoretical orientations to initiate or continue collaborative efforts to
enhance our knowledge about spiritually integrated psychotherapies
through practice-based evidence research.
3
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Received April 1, 2022
Accepted April 1, 2022 ▪