Religiously adapted CBT

1. Introduction

Version followed: Duke Religiously Integrated CBT (RCBT) for depression, the 10-session manual by Ciarrocchi, Schechter, Pearce, Koenig and colleagues (2014; adapted from A. T. Beck's CBT protocol, Templeton-funded), which exists in Christian, Jewish, Muslim (Shia; plus a Sunni adaptation), Hindu and Buddhist versions with a shared session structure. Session-level detail below was read from the opened Buddhist-version manual (Sessions 1-5) and from the Sunni "Islamic Integrated CBT" (IICBT) therapist workbook (Sabki, Sa'ari & Syed Muhsin, University of Malaya, 2018; Sessions 1-4). Christian specifics come from Michelle Pearce's 2022 Duke presentation and the contents of her 2016 book Cognitive Behavioral Therapy for Christians with Depression. The Christian and Jewish manual and workbook PDFs themselves are not drawn on here [uncertain: Christian- and Jewish-specific wording of each session]. [source: Duke CSTH therapy-manuals page; RCBT Buddhist manual; IICBT therapist workbook; Pearce 2022]

What it is: a manualised, individual CBT for depression (developed for people with chronic medical illness) in which standard CBT tools (behavioural activation, thought monitoring, disputation, relapse prevention) are kept, and the client's own religious beliefs, practices, texts and community are built into every tool as sources of evidence, motivation and coping. It is not a new theory of psychopathology; it is CBT delivered inside the client's religious frame. [source: Pearce et al. 2015 abstract; Pearce 2022]

How change is thought to happen: the CBT triangle of thoughts, feelings and behaviour is kept, with the client's religious tradition placed around it as a resource that informs all three; depressive thinking is changed partly by "renewing the mind" (filling it with memorised sacred texts and contemplative practice) and by disputing distorted beliefs with the client's own scripture and spiritual wisdom, while behaviour is changed through activation, community involvement, gratitude and service. [source: Pearce 2022; RCBT Buddhist manual Session 1] The Buddhist manual describes standard CBT as sitting within a wider religiously integrative CBT (a "square within a cube" image). [source: RCBT Buddhist manual]

Related versions not followed here: Rosmarin et al.'s spiritually integrated internet treatment for worry in religious Jews (2010; two weeks of daily access; targeted trust and mistrust in God; abstract only) [uncertain: its module content]; earlier Christian cognitive therapies (Propst; Pecheur & Edwards) are not drawn on here [uncertain].

2. Framework

Format [source: Pearce 2022; RCBT Buddhist manual Part I; IICBT workbook]:

• 10 individual sessions over about 12 weeks; 50 minutes (Session 1 may run 5-10 minutes longer; any session may be extended about 10 minutes, and uncovered material carries into the next session's review). Trial delivery was by phone, Skype or instant messaging by master's-level counsellors, using a therapist workbook (session notes per client) and a participant workbook the client brings every session.
• Every session follows the same nine-part template: goals; therapist pre-session preparation; materials; agenda; review of home practice; introduction of the new topic; in-session exercises; assignment of new home practice; termination with feedback. Home assignments are called "home practice activities".
• Keep the same weekly time, stress completing all 10 sessions, and arrange a make-up session if one is missed.
• Give emergency contact numbers before treatment starts.

Session sequence (titles from the Buddhist and IICBT tables of contents; the shared structure is confirmed across those two versions, inferred for Christian and Jewish versions [uncertain]):

Pearce's book version (Christian CBT, 2016) presents the same material as an assessment chapter, an introduction-of-the-model chapter, seven tools (Planting Truth; Metanoia/changing your mind; Redemptive Reframing; Reaching Out and Connecting; Acceptance and Forgiveness; Gratitude; Service) and a relapse-prevention chapter, with an appendix for clergy; the book reads as tool-based rather than strictly session-fixed. [source: Templeton Press book listing via UBC Press; contents only]

Criteria for moving on: the manual is a fixed sequence, not criterion-based. Within sessions it gives micro-criteria: correct thought logs (thoughts recorded, not feelings; one thought per line) before moving to disputation; practise steps D and E on the client's own logs until the client can do them unaided. [source: RCBT Buddhist manual Session 4; IICBT Session 4] Beyond this, no phase-transition criteria were found [uncertain]. Suggested practice: if a client cannot yet produce an ABC log after Session 3, repeat the ABC review at the start of Session 4 before teaching D/E; if mood is worsening or risk rises, pause the sequence and address safety first [synthesis].

3. Guiding principles

[source for this section: Pearce 2022; RCBT Buddhist manual Part I and Sessions 1-4; IICBT workbook Part I and Sessions 1-3; items marked [synthesis] are mine]

• Religion is in the room anyway. Meaning: ask how the client's faith can be a healing resource rather than whether to raise it.
• Work from the client's own tradition. Meaning: use the client's scriptures, practices, terms and community, not the therapist's; tailor examples from the Session 1 assessment.
• Start where the client is spiritually; add explicit religious material gradually. Meaning: in early sessions offer, don't presume, and step up religious content only as the client takes it up.
• Never argue about religious matters. Meaning: the IICBT workbook's maxim is, in effect, that winning the argument loses the client; reflect, ask and offer instead.
• Don't pathologise religion as a whole. Meaning: a particular belief may feed distress; the target is the gap between that belief or behaviour and the client's own deeper religious values, not faith itself.
• Explore spiritual suffering before trying to resolve it. Meaning: questions such as anger at God or feeling abandoned are listened to and validated first; meaning-making comes second.
• Clergy are complementary colleagues. Meaning: consult or refer to the client's clergy for theological questions outside your competence, with consent.
• Partnership, not lecture. Meaning: invite questions, check understanding, use the client's own examples rather than the manual's, keep didactic segments short.
• Praise outweighs correction. Meaning: praise effort on home practice several times per session; correct one log entry gently rather than many.
• The client is the best judge of their own thoughts. Meaning: offer categories or alternative views as suggestions; the client decides.
• Adhere to content and order; adapt wording. Meaning: keep the sequence and core exercises, phrase things naturally.
• Take responsibility for unclear assignments. Meaning: if home practice wasn't done, assume the instructions were unclear before assuming low motivation.
• Respect diversity within a tradition. Meaning: affiliation, practice and doctrine vary (the Duke set has separate Shia and Sunni Muslim versions; the Buddhist manual stresses differences by tradition and origin); ask rather than assume.
• Don't map one tradition's concepts onto another's. Meaning: the Buddhist manual warns against equating Buddhist ideas with Christian ones and notes karma can be misread as blame for illness; by extension, check that doctrines such as divine punishment, decree (qadr) or suffering-as-test are not being used against the self [synthesis for the Abrahamic extension].
• Safety and consent first. Meaning: emergency numbers before treatment; informed consent and ethical issues discussed in Session 1 (IICBT); depression-related suicidal thoughts are assessed under ordinary clinical standards [synthesis for the risk-assessment standard].
• Therapist competence in the tradition. Meaning: the IICBT workbook expects therapists to know Qur'an and Sunnah and to show honesty, trustworthiness and patience; Pearce points to spiritual-competency training; if you lack tradition knowledge, prepare texts with the client or clergy [synthesis for the last clause].
• Concepts belong to the tradition. Meaning: present God, sin, grace, revelation or the soul as the client's beliefs ("in your tradition..."), not as clinical facts; the therapist neither endorses nor disputes doctrine [synthesis].

4. Intervention inventory

Order follows the manual's sessions. Tradition notes: C = Christian, J = Jewish, M = Muslim. Scripture references are only those named in the sources; for other choices, select texts with the client (and their clergy if helpful) [synthesis]. All example language is illustrative unless quoted and cited.

4.1 Standard session routine (every session)

• Purpose: keep the 10-session protocol structured and collaborative. [source: RCBT Buddhist manual Part I; IICBT Part I]
• Steps: (1) Prepare beforehand from your therapist-workbook notes. (2) Set the agenda with the client and invite additions. (3) Mood rating: average mood for the past week on 0-10. (4) Review home practice: memory verse recited or read aloud, logs, contemplative practice, community contact, activities; praise effort and correct errors without judgment. (5) Introduce the new topic briefly. (6) Do the in-session exercise on the client's own material. (7) Assign the next home practice and check it is clear and feasible. (8) Ask for feedback; close.
• Example language (illustrative): "Before we start, what number from 0 to 10 fits your mood on average this week? ... And did you get a chance to work on the verse? Would you like to say it, or read it from the card?"
• Watch for: sessions turning into lectures; skipped home-practice review (which teaches that practice doesn't matter). Working: client arrives with the workbook and logs, and starts reporting practice unprompted [synthesis].

4.2 Rapport, orientation and consent (Session 1)

• Purpose: build the alliance and set expectations. [source: RCBT Buddhist manual S1; IICBT S1]
• Steps: (1) Introduce yourself and your training; IICBT invites the therapist to share credentials and ask the client's background; the Buddhist version says to acknowledge any personal background in the tradition. (2) Explain the programme's purpose, confidentiality, the 10-session commitment and rescheduling of missed sessions. (3) Affirm the client's beliefs and invite them to use their faith as far as they are comfortable. (4) Discuss consent and ethical issues (IICBT). (5) Give crisis contact numbers.
• Example language (illustrative): "This approach uses ordinary CBT tools, and it also lets us draw on your faith as much or as little as you want. You set the pace on that."
• Watch for: clients who fear the therapist will judge or dilute their faith, or (conversely) assume you share it; clarify your role [synthesis].

4.3 Spiritual and religious assessment (Session 1)

• Purpose: learn which beliefs, practices, texts and community the client has, and whether religion is currently comfort, strain or both; this drives every later tailoring choice. [source: RCBT Buddhist manual S1; IICBT S1; Pearce 2022]
• Steps: (1) Ask a short set of flexible open questions (the Buddhist manual uses six): the role of religion in the client's life; current practice and reading; community membership; how the depression or illness has affected their spiritual life. (2) The IICBT workbook uses a modified IIUM Religiosity Scale (yes/no items grouped under Islam, Iman and Ihsan); use it only as published and licensed, items not reproduced here. (3) Pearce's case material asks whether religion is a source of comfort or of pain for the client; include this. (4) Note texts, practices and people the client already values for later sessions.
• Example language (illustrative): "What part does your faith play in your life day to day? ... Since the depression began, has your relationship with God felt different?"
• Watch for: negative religious coping (feeling punished or abandoned), loss of practice due to illness, and strain with a congregation; flag these for Sessions 5-6 [synthesis for flagging].

4.4 Problem assessment and prioritising (Session 1)

• Purpose: agree treatment targets. [source: RCBT Buddhist manual S1; IICBT S1]
• Steps: (1) Ask for 2-4 main reasons for seeking help (about 5 minutes). (2) Reflect and empathise. (3) Ask which to prioritise.
• Example language (illustrative): "Of these, which would make the biggest difference if it eased?"
• Watch for: illness-related problems that need medical rather than psychological input; note them for liaison [synthesis].

4.5 CBT rationale (Session 1)

• Purpose: teach that interpretations shape emotions and behaviour, and the vicious cycle of depressive thinking and withdrawal. [source: RCBT Buddhist manual S1; IICBT S1]
• Steps: (1) Give a short everyday example (the manual uses one about a flat tyre and a neighbour's response); prefer an example from the client's own week. (2) Show how a negative interpretation leads to low mood and withdrawal, which confirms the interpretation. (3) Link behaviour to mood: pleasant activity lifts mood, avoidance deepens it. (4) Check understanding.
• Example language (illustrative): "Two people can have the same thing happen and feel quite differently, depending on what they tell themselves it means."
• Watch for: client hearing "it's all in your head"; validate the reality of illness and losses [synthesis].

4.6 Religiously integrative rationale (Session 1)

• Purpose: show the client that the link between thought, feeling and action is also found in their own tradition, so the CBT work feels like faith-consistent practice. [source: RCBT Buddhist manual S1; IICBT S1; Pearce 2022]
• Steps: (1) Present a text or teaching from the client's tradition on the mind shaping life. (2) M (IICBT): al-Ghazali's "therapy of opposites" and Qur'anic verses, including 13:11 (God changes a people's condition when they change themselves), 2:155-157 (trials and patience), 6:48 and 46:13 (no fear or grief for the steadfast); the IICBT frame is al-Ghazali's purification-of-the-soul stages (self-knowledge, purification, cultivation, self-evaluation, happiness), as the workbook's authors present it. (3) C: Pearce's "renewing your mind" and "Metanoia" framing (Christian vocabulary of mind renewal and change of mind) [source: Pearce 2022; book contents]. (4) J: use teachings from Torah and Talmud as the Duke Jewish manual does [source: Pearce 2022; specific passages uncertain]. (5) Ask the client how this fits their own understanding.
• Example language (illustrative): "Your tradition has a lot to say about guarding and renewing the mind. Does that ring true for you?"
• Watch for: proof-texting that feels imposed; pull back and let the client supply texts [synthesis].

4.7 Renewing the mind: memory-verse practice (Sessions 1-10)

• Purpose: "plant" truthful, hopeful thoughts by memorising a short sacred text each week, so that it gradually reshapes habitual thinking (Pearce's "Planting Truth"). [source: Pearce 2022; RCBT Buddhist manual S1-4; IICBT S1-3]
• Steps: (1) Explain the rationale: memorised texts act like seeds that slowly change the mind. (2) Ask whether the client already memorises or meditates on texts. (3) Assign one verse or short text per week; client writes it out and posts it where it will be seen. (4) Start each session by having the client recite or read it, and praise the attempt. (5) Choose later verses to fit the session theme (e.g. hardship, trust, gratitude).
• Tradition notes: C: Pearce uses Romans 8:1 against shame, Philippians 4:6 for anxious courage through prayer with thanksgiving, James 1:5 on asking God for wisdom. M (IICBT): weekly items include a hadith on seeking forgiveness (istighfar), dhikr phrases and a du'a for peace, and formulas seeking refuge (ta'awwudh), with set daily repetitions. J: Torah/Talmud texts per the Duke Jewish version [uncertain which].
• Example language (illustrative): "This week's verse is short. Write it on a card by the kettle, and each time you see it, read it slowly once."
• Watch for: verses chosen by the therapist that the client experiences as rebuke; texts that, in the client's reading, imply punishment. Working: the client starts spontaneously recalling the text in low moments [synthesis].

4.8 Activity and mood monitoring (Session 1 home practice)

• Purpose: baseline for behavioural activation and evidence of the mood-activity link. [source: RCBT Buddhist manual S1; IICBT S1]
• Steps: (1) Give the activity-and-mood log. (2) Ask the client to record what they did roughly every two hours (IICBT allows twice daily), including trivial activities, with a mood rating. (3) Bring logs to every session and review patterns together.
• Example language (illustrative): "Even 'sat in the chair' counts. We're looking for patterns, not achievements."
• Watch for: blank logs from fatigue or illness; shorten the interval demand rather than abandoning monitoring [synthesis].

4.9 Alternative viewpoints with religious perspective (Session 2)

• Purpose: first, gentle practice in seeing a situation differently, including from the client's faith. [source: RCBT Buddhist manual S2; IICBT S2]
• Steps: (1) Take a real situation from the week. (2) Generate several ways of seeing it and the feelings and actions each would produce. (3) Ask what the client's religious beliefs might suggest as another perspective. M (IICBT): Qur'an 2:216, that something disliked may be good and God knows what people do not.
• Example language (illustrative): "If someone in your congregation you respect looked at this, how might they see it?"
• Watch for: alternatives that dismiss real pain; validate before offering views [synthesis].

4.10 Behavioural activation and pleasant-activity planning (Session 2 onward)

• Purpose: rebuild pleasure and mastery and break avoidance. [source: RCBT Buddhist manual S2-3; IICBT S2-3]
• Steps: (1) Give the rationale (action lifts mood; avoidance spirals down). Link to the client's tradition (IICBT: service to others as worship; Buddhist version: balanced pleasure is not attachment). (2) The client picks two activities, each longer than 10-15 minutes, that can be done in a day. (3) Fill in the planning worksheet: activity, place, date, time. (4) Brainstorm barriers in advance, including physical limits, travel and illness (IICBT). (5) Client records completion and mood afterward. (6) Add one more activity each following week (Session 3).
• Example language (illustrative): "Let's pick two things that fit your energy right now, and pin down exactly when and where."
• Watch for: guilt about pleasure ("I should be praying, not enjoying myself"); explore the client's own tradition's view of rest and joy. Working: mood ratings rise on activity days [synthesis].

4.11 Power of people / Reach out and connect (Session 2 onward)

• Purpose: counter isolation and build purposeful activity through the faith community. [source: RCBT Buddhist manual S2-3; IICBT S2-3; Pearce 2022]
• Steps: (1) Identify supportive people in the client's faith community, ideally local and not family. (2) Assign contacting at least one person before next session. (3) Pearce's version: take part actively in the community, support others, and choose one person to spend time with and pray for. M (IICBT): mutual prayer and support within the community. (4) Review contacts at each session.
• Example language (illustrative): "Who at your church, mosque or synagogue would you feel okay calling this week, even briefly?"
• Watch for: clients without a community, or harmed by one; many members of some traditions are unaffiliated (Buddhist manual). Offer alternatives such as online communities, chaplaincy or a single trusted believer [synthesis].

4.12 ABC thought monitoring (Session 3)

• Purpose: build awareness of automatic thoughts that drive mood shifts. [source: RCBT Buddhist manual S3; IICBT S3]
• Steps: (1) Bridge from the activity review: if mood rose with activity, reinforce that; if not, use it to open the role of thoughts. (2) Rationale: negative self-talk is habitual and often outside awareness; it must be noticed before it can be changed (IICBT links this to Qur'an 50:16, God knowing the soul's whispers). (3) Teach A = activating event (who, what, where, when), B = beliefs and interpretations, C = consequences (emotions rated 0-10, plus behaviour). (4) Fill in one real example together on the worksheet. (5) Home practice: one ABC log per day (seven in the week).
• Example language (illustrative): "When your mood dropped yesterday, what was going through your mind just then?"
• Watch for (Session 4 review): feelings written in the B column, and several thoughts bundled together; correct at least one entry with praise.

4.13 Unhelpful thinking styles with theological reflections (Sessions 2-4)

• Purpose: help the client label their distortions and see why their own tradition also calls them untrue or unhelpful. [source: RCBT Buddhist manual S2-3; IICBT S3; Pearce 2022]
• Steps: (1) Client reads the workbook's ten categories one page a day after Session 2. (2) In Session 3 review each: name, definition, example, why it's unhelpful, and the tradition's reflection. The ten (IICBT list): all-or-nothing thinking, overgeneralisation, mental filter, disqualifying the positive, jumping to conclusions (mind-reading, fortune-telling), magnification/minimisation, emotional reasoning, "should" statements, labelling, personalisation. (3) Ask which are the client's "favourites" and normalise (everyone, therapists included, has some). (4) Categorise the client's own ABC thoughts and ask why. (5) Session 4: review 2-3 categorised thoughts.
• Tradition notes: M (IICBT) pairs categories with themes such as God's blessings against the mental filter, trust in God against fortune-telling, not presuming others' hearts against mind-reading, and Qur'an 2:286 (no soul burdened beyond capacity) against "should" statements. C: Pearce gives theological reflections on labelling, "shoulds" and fortune-telling [uncertain: specific wording].
• Example language (illustrative): "Which of these do you catch yourself doing most? ... Does your tradition expect you to manage more than you're able?"
• Watch for: the client using categories to criticise themselves ("I even think wrong"); keep it curious [synthesis].

4.14 Contemplative prayer or meditation on a verse (Session 3 onward)

• Purpose: deepen "renewing the mind" by dwelling on a text rather than only memorising it. [source: RCBT Buddhist manual S3; IICBT S3; Pearce 2022]
• Steps: (1) Distinguish it from breath-focused meditation: here attention rests on a sacred text. (2) Guide the client through it in session: read the verse slowly, pause, reflect on a word or phrase, repeat it, and use it as a focus of prayer or listening (IICBT sets this out as an eight-step tafakkur/dhikr method). (3) When the mind wanders, notice the thought and let it pass, like boats passing on a river, then return to the text. (4) Home practice: about 20 minutes daily, using the week's memory verse. (5) Review the experience next session.
• Example language (illustrative): "Read it once slowly. Now stay with whichever word stands out... if thoughts come, let them float past and come back to that word."
• Watch for: rumination dressed as prayer; scrupulous worry about praying "correctly"; re-experiencing or depersonalisation in contemplative practice (reported for meditation in vulnerable clients). Shorten sessions, keep eyes open, ground and review [synthesis]. Working: the client reports calmer starts to the day or reaching for the practice when distressed.

4.15 ABCDE disputation with religious resources (Session 4 onward)

• Purpose: change distorted beliefs using evidence plus the client's own scripture and spiritual wisdom (Pearce's "Changing your mind" / Metanoia; IICBT "Bringing All Thoughts Captive"). [source: RCBT Buddhist manual S4; IICBT S4; Pearce 2022]
• Steps: (1) Didactic on interpretation: the same event (the manual uses rain on a planned walk) produces different moods depending on meaning; illness outcomes partly depend on the meaning given to illness. (2) Religious application: a teaching that joy or contentment need not depend on circumstances (M, IICBT: 2:155-156, patience in trials and returning to God). (3) Add D = dispute (Buddhist version: "disengage/explore") using the Disputing Questions sheet: evidence for and against, alternative explanations, evidence of coping ability, and what the client's sacred texts, teachings and worldview say. Pearce's version also names the thinking style and rates feelings 1-10 before and after. (4) Add E = new belief and its emotional and behavioural consequences (re-rated). (5) Work through several of the client's logged thoughts (about 15 minutes) until they can do D and E unaided. (6) Home practice: at least one ABCDE log daily.
• Tradition notes: C: Pearce cites Romans 8:1 as a "shame-buster" and Philippians 4:6 as a courage-booster when disputing. M: verses on hardship followed by ease (94:5-6) and remembrance bringing peace (13:28) appear in IICBT. J: Torah/Talmud resources [uncertain which].
• Example language (illustrative): "The thought is 'God has given up on me.' What does your own scripture say about that? ... What would you now say to yourself instead, and how strong is the sadness when you say it?"
• Watch for: using scripture to argue the client out of feelings; texts the client experiences as condemning. Working: emotion ratings drop after E and the client generates the religious counter-evidence themselves.

4.16 Religious practices as behavioural experiments (Session 4 onward)

• Purpose: test predictions by doing a practice (e.g. prayer, a community act) and observing mood. [source: IICBT S4, named only; RCBT Buddhist manual S4 goals; detailed steps uncertain]
• Steps [synthesis, standard CBT experiment format]: (1) State the prediction ("if I pray I'll feel nothing"). (2) Plan the practice, when and how long. (3) Rate mood before and after. (4) Review what happened against the prediction.
• Example language (illustrative): "Let's treat it as an experiment rather than a test of your faith."
• Watch for: framing an unhelpful result as spiritual failure; stress it tests the prediction, not the client [synthesis].

4.17 Reviewing significant events (Session 5 onward)

• Purpose: consolidate skills by reviewing depression- or illness-related events of the week. [source: RCBT Buddhist manual S5]
• Steps: (1) Ask about significant events and which integrative strategies were used. (2) For difficult moments, ask what could be done differently, treating them as learning, not failure.
• Example language (illustrative): "Looking back at Thursday, which tool might have helped, and what got in the way?"
• Watch for: self-blame; keep a learning frame.

4.18 Loss inventory, including sacred losses (Session 5)

• Purpose: name the losses from illness and depression, including spiritual ones, as a basis for grieving, acceptance and meaning-making. [source: RCBT Buddhist manual S5; partial text, later steps not drawn on]
• Steps: (1) Introduce three loss domains: identity, capacities, relationships; draw on assessment material. (2) Ask about specific losses (relationships, time with loved ones, recreation, work, sense of self, social activities) and have the client rate each 0-10 for severity. (3) Ask about sacred or spiritual losses (e.g. no longer able to attend worship or fast, a changed sense of God) [example losses are synthesis]. (4) Lead into control versus active surrender (4.19).
• Example language (illustrative): "Illness takes things from us, some visible, some not. What has it taken from you, including in your spiritual life?"
• Watch for: grief that is complicated or traumatic; disclosures of spiritual abandonment (move to 4.20).

4.19 Acceptance and active surrender (Session 5; Pearce tool "Letting Go and Letting God")

• Purpose: distinguish what can be changed from what cannot, and practise an active, spiritually motivated letting-go of the latter. [source: Pearce 2022; RCBT Buddhist manual S5 goals and materials (Active Surrender Exercise)]
• Steps: (1) Review what the client is trying to control. (2) Sort into controllable and not controllable. (3) For the uncontrollable, choose a surrender form: a prayer, a letter to God, an empty-chair dialogue (Gestalt), or a symbolic action. (4) Emphasise surrender as intentional and active, not passive giving up. (5) Keep acting on the controllable parts (e.g. treatment adherence) [synthesis].
• Example language (illustrative): "Surrender here doesn't mean giving up. It means deliberately handing over what you can't carry, so you can put your energy where it counts."
• Watch for: surrender used to avoid medical care or necessary action (pair it with an action plan) [synthesis]; empty-chair work raising strong affect; leave time to settle.

4.20 Redemptive reframing (Pearce tool; likely Session 6, "spiritual struggles")

• Purpose: work with spiritual suffering, then look for meaning and blessing within it. [source: Pearce 2022; book chapter title; session mapping uncertain]
• Steps: (1) Step 1, explore: invite the hard questions (Why did God allow this? Is my anger at God sinful? Is God punishing or abandoning me?). Listen and validate; the aim is exploration, not answers. (2) Step 2, reframe: only when the client is ready, ask where God may have been at work and what blessings or growth may be present (meaning-making, benefit-finding). (3) Choose a setting for processing: journal, therapist, or clergy.
• Example language (illustrative): "It sounds as if you're angry with God and also afraid that being angry is wrong. Can we make room for both before we try to make sense of it?"
• Watch for: premature reframing (feels dismissive); clients from traditions where questioning God feels forbidden (offer clergy input). Working: the client can name both the loss and some meaning without one cancelling the other [synthesis].

4.21 Forgiveness of self, others or God (Pearce tool "Acceptance and Forgiveness")

• Purpose: release resentment and self-condemnation that maintain depression. [source: Pearce 2022]
• Steps: (1) First process and validate the hurt. (2) Explain two kinds: decisional (a choice to release the debt) and emotional (a later change in feeling). (3) Identify the target: self, another person, or God. (4) Support the decision through the client's practices (e.g. prayer, a letter); M: istighfar practice from Session 1 supports self-forgiveness themes [link is synthesis]. (5) Let emotional forgiveness follow at its own pace.
• Example language (illustrative): "Deciding to forgive can come before the feelings do. Would a decision be possible, even if the hurt is still there?"
• Watch for: pressure to forgive abuse or to stay in danger; forgiveness is not reconciliation and does not cancel safety or reporting duties [synthesis].

4.22 Gratitude (Session 7; Pearce tool "Saying Thanks")

• Purpose: shift attention to what is going well and build new beliefs from it. [source: Pearce 2022; session content not drawn on]
• Steps: (1) Gratitude list of at least ten items. (2) "Renew the mind with gratitude": build alternative beliefs from what is going well. (3) Write a letter of thanks to someone who made a difference. (4) Prayers of thanksgiving, including brief prayers through the day to refocus attention. Pearce also mentions being a "two-way thanker" [uncertain meaning].
• Example language (illustrative): "Let's start the list with small things; they count."
• Watch for: gratitude used to invalidate pain ("I shouldn't complain"); keep both [synthesis].

4.23 Giving back: service, altruism and generosity (Session 8; Pearce tool "Service")

• Purpose: restore purpose, connection and self-worth through serving others, framed in the client's tradition. [source: Pearce 2022; IICBT S2 (service as worship)]
• Steps: (1) Plan one act of service: who, what, where, when, how and why. (2) Fit it to the client's physical capacity [synthesis]. (3) Afterward assess the impact on mood, energy, relationships, self-esteem and spirituality.
• Example language (illustrative): "What's one small thing you could do for someone this week that fits your energy?"
• Watch for: over-giving or martyrdom patterns; service as atonement for guilt [synthesis].

4.24 Stress-related and spiritual growth (Session 9) [uncertain: manual content]

• Purpose (from title): help the client recognise growth arising from illness and struggle.
• Steps [synthesis]: review the loss inventory and redemptive reframing; ask what strengths, values or spiritual depth have emerged; record them; link them to the client's tradition's own teaching on trial and growth, chosen with the client.
• Example language (illustrative): "Alongside everything you've lost, has anything grown in you through this?"
• Watch for: imposing growth on someone still in acute grief.

4.25 Hope and relapse prevention (Session 10; Pearce book chapter 11) [uncertain: manual content]

• Purpose: consolidate tools and plan for setbacks.
• Steps [synthesis, standard CBT relapse prevention]: (1) Review mood ratings across treatment. (2) List which tools helped most (verse, contemplative practice, ABCDE, activities, community, gratitude, service). (3) Name early warning signs and high-risk times (e.g. medical setbacks). (4) Write a plan: which tools to use, who to contact (community member, clergy, clinician). (5) Choose texts of hope from the client's tradition to keep. (6) Arrange follow-up or booster contact if available.
• Example language (illustrative): "If you notice the old heaviness coming back, what will be your first three steps?"
• Watch for: anxiety about ending; residual risk needing ongoing care.

4.26 Clergy consultation and referral (any session)

• Purpose: handle theological questions beyond the therapist's role and enlist faith-community support. [source: Pearce 2022; Pearce book Appendix A "For Clergy" (not drawn on)]
• Steps: (1) Get the client's consent. (2) Clarify roles: therapist for the psychological work, clergy for theological and pastoral questions. (3) Consult or refer as appropriate; clergy can be one place to process redemptive-reframing questions. (4) Agree what is shared [synthesis].
• Example language (illustrative): "That's a real theological question. Would it help to take it to your pastor, rabbi or imam as well as working on it here?"
• Watch for: clergy advice that conflicts with medical care or safety; see Section 5.

5. Handling problems

Source-based guidance is tagged; the rest is [synthesis].

Home practice not done. Praise whatever was done, explore barriers, problem-solve, and take responsibility for unclear instructions so the client doesn't feel they failed; call it "home practice", not homework. [source: RCBT Buddhist manual Part I; IICBT Part I] Also shrink the task (one verse line, one log a day), tie it to an existing prayer or worship time, and do the first entry together in session [synthesis].

Mood not lifting after activation (stuck). If activities didn't improve mood, use that as the opening to examine the thoughts accompanying them. [source: RCBT Buddhist manual S3; IICBT S3] If depression stays flat by mid-treatment: check medical contributors and medication with the medical team, review whether religious tasks have become further "shoulds", and consider whether the client needs more conventional CBT and less religious content [synthesis].

Resistance to the model. Elicit feedback, explore the beliefs behind the reluctance, and offer alternatives; the client need not fully agree with the model. [source: IICBT S1-2] Avoid lecturing and never argue doctrine. [source: IICBT S1; RCBT Buddhist manual S1]

Client less religious, ambivalent, or doubting. Start where the client is and introduce explicit religious content gradually. [source: RCBT Buddhist manual Part I; IICBT S1] Let the client decide how much faith content to use; if they want little or none, drop the religious elements and deliver standard CBT (Duke also produced a conventional CBT manual set, listed for research use only) [synthesis; source for the CCBT set: Duke manuals page]. Treat doubt as a topic to explore, not a symptom to fix [synthesis].

Belief that God is punishing or has abandoned them; anger at God. Explore first, validate, don't rush to resolve (redemptive reframing, Step 1); identify discrepancies between this belief and the client's own wider beliefs; forgiveness can include God; surrender can take the form of a letter to God; clergy can help process the questions. [source: Pearce 2022] Don't present your own theology as the answer [synthesis].

Doctrine used as self-blame. The Buddhist manual warns that karma can be misread as blame for illness or depression. [source: RCBT Buddhist manual] Watch for the Abrahamic equivalents (illness as punishment for sin, a test the client is "failing", insufficient faith causing illness); explore what the client's own tradition and clergy actually teach, and use the ABCDE log on the self-blaming inference, not the doctrine [synthesis].

Religious guilt and scrupulosity. Not addressed directly in the opened manuals; nearest material is the work on "should" statements, self-criticism and seeking forgiveness (IICBT) [source: IICBT S1, S3]. If guilt is obsessional (repetitive checking of prayers, purity, blasphemous intrusions, constant reassurance-seeking), assess for OCD; then memorised verses and disputation can become reassurance rituals, and exposure and response prevention, ideally coordinated with clergy, is the better fit [synthesis].

Overwhelm during loss, surrender, empty-chair or forgiveness work. Slow down, return to validating the pain, and save meaning-making for later; finish the session with grounding and a concrete plan. Use the empty chair only when the client has enough stability; offer the letter or prayer option instead [synthesis; the tool options are from Pearce 2022].

Contemplative practice going badly. If practice has gone poorly, be supportive and encourage another try [source: RCBT Buddhist manual S4]. If it brings up intrusive memories, panic, depersonalisation or unusual experiences, cut to brief eyes-open practice or verse recitation only, ground, and assess for trauma or psychosis before continuing [synthesis].

Physical illness limits. Brainstorm barriers such as travel and illness ahead of time [source: IICBT S2]; use remote sessions as the trial did [source: Pearce 2022]; scale activity and service tasks to energy levels [synthesis].

No faith community, or harm from one. Many members of some traditions have no community (Buddhist manual) [source]. If the client has been hurt by a congregation or leader, don't push community contact; explore safer sources of support (a single trusted believer, chaplaincy, a different congregation of their choosing) [synthesis].

Suicidal thoughts. The manuals require crisis numbers before treatment and say to stabilise and ensure safety in emergencies; IICBT notes depressed clients may have thoughts of not wanting to live, but neither opened manual gives a risk protocol. [source: RCBT Buddhist manual Part I; IICBT] Use your service's standard practice: ask directly, assess ideation, intent, plans, history and protective factors; build a written safety plan; do lethal-means counselling (safe storage or removal); involve emergency services when risk is imminent. Religious beliefs against suicide may protect, but shame about such thoughts can stop disclosure; don't treat a prohibition as a safety plan on its own [synthesis].

Ruptures. Typical triggers: the client feels the therapist is preaching, choosing texts that judge, or quietly disapproving of their faith; or a client who shares the therapist's faith assumes agreement. Name it, ask what felt wrong, take responsibility, and hand text choice back to the client [synthesis].

Diversity within the tradition. Duke has separate Shia and Sunni Muslim versions [source: Duke manuals page]. Denomination, observance and practice also vary among Christian and Jewish clients; ask which texts, translations and practices fit them and don't assume a shared canon or interpretation [synthesis].

Religious content in psychosis or mania. Distinguish culturally normative belief and experience from delusion by asking how others in the client's community see it (with consent, ask clergy too); don't dispute religious delusions with scripture; assess and refer to psychiatric care [synthesis].

Clergy or community advice that conflicts with care. Some clients hear that faith should replace medication or therapy, or that abuse should be handled privately within the community. Respect the role of clergy while stating the clinical facts, keep medical care and safety in place, and follow mandatory reporting and safeguarding rules for any abuse disclosure whatever the community's preference. Don't take part in conversion or "change" efforts on sexual orientation or gender identity, even if framed in religious terms [synthesis; no source addresses these concerns, uncertain how often they arise].

Therapist competence limits. The IICBT workbook expects knowledge of Qur'an and Sunnah [source: IICBT]; Pearce points to spiritual-competency training [source: Pearce 2022]. If you lack tradition knowledge, say so, let the client teach you, prepare texts with them or their clergy, and get supervision [synthesis].

Sources

Sources:

• Therapy manuals - Duke Center for Spirituality, Theology and Health
• RCBT manuals and workbooks page - Duke CSTH
• RCBT Manual, Buddhist Version (Ciarrocchi, Schechter, Pearce, Koenig, Kristeller, 2014), text read to Session 5
• IICBT Therapist Manual Workbook, Sunni Muslim version (Sabki, Sa'ari & Syed Muhsin, 2018), text read to Session 4
• Pearce, M. Religiously Integrated CBT, Duke 2022 presentation
• Pearce et al. 2015, abstract - Duke Scholars
• Rosmarin et al. 2010, record - Harvard DASH
• Pearce 2016 book listing - UBC Press

Publications cited:

• Pearce, M. J., Koenig, H. G., Robins, C. J., Nelson, B., Shaw, S. F., Cohen, H. J., & King, M. B. (2015). Religiously integrated cognitive behavioral therapy: A new method of treatment for major depression in patients with chronic medical illness. Psychotherapy, 52(1), 56-66. (abstract only)
• Pearce, M. (2016). Cognitive Behavioral Therapy for Christians with Depression: A Practical Tool-Based Primer. Templeton Press. (contents only)
• Rosmarin, D. H., Pargament, K. I., Pirutinsky, S., & Mahoney, A. (2010). A randomized controlled evaluation of a spiritually integrated treatment for subclinical anxiety in the Jewish community, delivered via the Internet. Journal of Anxiety Disorders, 24(7), 799-808. (abstract only)

Further reading (not drawn on) [uncertain]: the Duke Christian, Jewish and Shia Muslim RCBT manuals and workbooks; Sessions 6-10 of every manual version; the full text of Pearce et al. 2015; Propst's and Pecheur & Edwards' Christian cognitive therapy studies.