A randomized controlled evaluation of a spiritually integrated treatment for subclinical anxiety in the Jewish community, delivered via the Internet

Abstract

Objective

This study evaluated the efficacy of a spiritually integrated treatment (SIT) for subclinical anxiety in the Jewish community.

Method

One hundred and twenty-five self-reported religious Jewish individuals with elevated levels of stress and worry received SIT (n = 36), progressive muscle relaxation (PMR, n = 42), or a waitlist control condition (WLC, n = 47). SIT and PMR participants accessed Internet-based treatment on a daily basis for a period of 2 weeks. All participants completed self-report assessments at pre-treatment (T1), post-treatment (T2), and 6–8-week follow-up (T3).

Results

SIT participants reported large improvements in primary (stress and worry) and secondary (depression and intolerance of uncertainty) outcomes, and moderate improvements in spiritual outcomes (positive/negative religious coping; trust/mistrust in God). SIT participants reported greater belief in treatment credibility, greater expectancies from treatment and greater treatment satisfaction than PMR participants. SIT participants also reported better improvements in both primary outcomes (stress and worry), one of two secondary outcomes (intolerance of uncertainty), and two of four spiritual outcomes (positive religious coping and mistrust in God) compared to the WLC group, whereas PMR and WLC participants did not differ on most outcomes.

Conclusions

Results of this investigation offer initial support for the efficacy of SIT for the treatment of subclinical anxiety symptoms among religious Jews. Results further suggest that it is important to incorporate spiritual content into treatment to help facilitate the delivery of psychotherapy to religious individuals.

Introduction

Chronic anxiety, even at subclinical levels, has been identified as a risk factor for a number of major health problems including hypertension (McEwen, 1998), asthma (Sandberg et al., 2000), diabetes (Soo & Lam, 2009), pain (Beesdo et al., 2009) and cardiovascular disease (Brosschot, Van Dijk, & Thayer, 2007). Fortunately, strong empirical evidence supports cognitive behavioral techniques such as progressive muscle relaxation (PMR) as clinically efficacious in reducing symptoms of stress and worry (Borkovec, Newman, Pincus, & Lytle, 2002). However, while PMR is used widely in clinical and health psychology settings (Pluess, Conrad, & Wilhelm, 2009), religious individuals tend to be reluctant to access conventional psychological services due to a preference for spiritually integrated care (Lindgren and Coursey, 1995, Puchalski et al., 2001). Furthermore, considerable evidence suggests that religion can be both a significant resource for people in times of distress (Pargament, 1997), and a source of struggle and strain (Exline, Yali, & Sanderson, 2000). These facts have led to the development of several spiritually integrated treatments (SITs) in recent years to provide religious communities with culturally appropriate services (Pargament, 2007). Spiritually integrated treatments are similar to conventional psychotherapy except that the rationale for treatment may be presented in a spiritual framework, maladaptive spiritual beliefs are targeted explicitly, and spiritual/religious practices can be purposefully included as behavioral activation strategies with the intention of increasing positive emotions such as gratitude and hope (Paukert et al., 2009, Rosmarin et al., 2010).

While research on SITs is still in its early stages, more than 30 clinical trials have been conducted, including several prominent randomized controlled studies (e.g., Oman et al., 2006, Propst et al., 1992, Rye et al., 2005, Wachholtz and Pargament, 2009). One meta-analysis found that religion-accommodative and conventional treatments were equally effective in reducing depressive symptomatology (McCullough, 1999), suggesting that SITs can be offered when preferred by clients without compromising treatment efficacy. Another more recent meta-analysis by Smith, Bartz, and Richards (2007) found that SITs were more effective than conventional treatments, with a between-groups effect size of 0.51 among 24 studies. These latter finding should be interpreted cautiously, however, because the majority of studies reviewed in this meta-analysis did not use manualized treatments or employ fidelity checks. Nevertheless, available evidence suggests that SITs can be effective and particularly appealing to religious populations (Hook et al., 2009). However, SITs remain largely unavailable. In particular, no SITs for practicing Jewish individuals have been developed or evaluated to date, a fact that is especially unfortunate as there are numerous barriers to the dissemination of psychotherapy in the Jewish community. Specifically, consultation and collaboration with religious leaders is often a prerequisite for religious Jews entering treatment (Greenberg, 1991), and stigma is often present, posing a barrier to treatment seeking (Paradis et al., 1997, Pirutinsky et al., 2009).

One spiritual construct that could be integrated into a treatment program for Jews is trust/mistrust in God. Trust in God has its origins in traditional Jewish thought (Ibn Pekuda, 1996) and involves the conviction that God takes care of one's best interests. By contrast, some religious individuals may develop mistrust in God, involving the belief that God is intentionally ignorant or malevolent and a sense that God cannot or will not provide for one's wellbeing (Rosmarin, Pargament, & Mahoney, 2009). In two recent investigations with large community samples of believers, trust in God was associated with less anxiety and depression, whereas mistrust in God was associated with higher levels of symptoms (Rosmarin et al., 2009a, Rosmarin et al., 2009c). Moreover, several psychological processes may tie trust/mistrust in God to stress and worry. Perceptions of adversity may be shaped by the beliefs associated with trust in God. A worldview in which God is wholly knowledgeable, powerful, and good may generate positive appraisals and prevent or reduce negative appraisals of stressful life events. The core beliefs of trust in God may further mitigate intolerance to uncontrollability and unpredictability, two cognitive factors that have been identified as important in maintaining worry (Behar, Dobrow-DiMarco, Hekler, Mohlman, & Staples, 2009). Trust in God may also contribute to positive religious coping (Pargament, 1997) and act as a psychological resource in times of stress by promoting spiritual support, a sense of connectedness with a transcendent force, and/or positive spiritual emotions such as inspiration, meaning, hope, and gratitude. By contrast, belief in a malevolent God may engender negative perceptions of threat and increase appraisals of danger, especially in situations that are uncontrollable or unpredictable. Mistrust in God may further exacerbate stress and worry by promoting spiritual struggles involving fundamental questions, doubts, conflicts and with the Divine.

One promising format for delivery of SITs to religious communities involves the use of electronic therapy (e-therapy). Clinical researchers could collaborate with spiritual/religious leaders to incorporate spiritual content into e-therapy protocols at the design level. Additionally, by enabling religious individuals to participate in treatment in a private setting such as their home, spiritually integrated e-therapies may help to facilitate dissemination despite stigma. Furthermore, recent research suggests that Internet use has become increasingly accepted in religious Jewish communities, even among more cloistered sects (Hack, 2007). This is particularly the case when Internet use for specific purposes is explicitly sanctioned by community leaders. While we are unaware of any previous attempts to integrate spiritual or religious content into e-therapy, in recent years, the efficacy of Internet-based interventions has been established in the treatment of a variety of difficulties including social phobia (Andersson et al., 2006), insomnia (Strom, Pettersson, & Andersson, 2004), and eating disorders (Winzelberg et al., 2000).

The present study therefore evaluated efficacy of a short-term SIT for subclinical anxiety among Jews, delivered via the Internet. To this end, a spiritually based audio/video treatment program was developed through extensive consultation with ultra-Orthodox Jewish religious leaders and teachers. To test the relative efficacy of this program, we administered progressive muscle relaxation (PMR) in similar electronic format to a comparison group, and a third group was randomized to a waitlist control (WLC) and received no treatment. We proposed the following hypotheses:

• SIT participants would report higher levels of belief in treatment credibility, have higher expectations of treatment, report more treatment satisfaction, and be more likely to complete treatment than PMR participants.

• Primary (stress and worry) and secondary (depression and intolerance of uncertainty) treatment gains would be greater for SIT participants compared to PMR and WLC participants at post-treatment and follow-up.

• Spiritual treatment gains (trust/mistrust in God and positive/negative religious coping) would be greater for SIT participants than PMR and WLC participants at post-treatment and follow-up.

• Treatment effects for SIT and PMR participants would be moderated by pre-existing Jewish religiousness (i.e., Orthodox Jews would be more likely to benefit from SIT than PMR).