Centrality of Religiosity as a Resource for Therapy Outcome?
Round 1
Reviewer 1 Report
This paper will be a good addition to the extensive literature on the relationship between religious beliefs and practices and health. The introduction of the concept of 'centrality' is a helpful and clarifying one. It would have been nice to see a study that goes beyond the dominant (in the Western world) Judeo-Christian concept of God and into more diverse religious backgrounds and practices and the differences these might make in a therapeutic context. But that is a different study.
Author Response
Dear Reviewer,
thank you for the kind revision.
Reviewer 2 Report
The review of the article:
“Centrality of Religiosity as a resource for therapy outcome? – Thinking about the role of attachment to God”.
First, thank you for the opportunity to review this manuscript. The Authors of this study were to examined the influence of one’s personal religious construct system for therapy outcome. Generally, the paper contains many positive and valuable aspects, however, I see also a number of comments related to the content of the manuscript.
The most unclear in the reviewed paper is, in my opinion, the way the Authors connect the centrality of religiosity and attachment to God. The Authors assumed that attachment to God plays a key role in patients with high centrality of religiosity (Lines 292-293: “Therefore, it is assumed that for patients with a high centrality of the religious construct system the perceived attachment to God takes a central position within the individual’s personality”). This assumption was not only not examined empirically (centrality is tested throughout the article), but the Authors did not explained anything about why they think high centrality is associated with attachment to God and what type of attachment is associated with centrality. Furthermore, it is unclear whether: (1) high centrality is related to the importance of attachment to God for the individual or (2) high centrality is associated with a particular type of attachment, for example with high secure attachment and low anxious attachment or vice versa? This has not been explained sufficiently in the paper. Measuring centrality with the CRS does not allow conclusions to be drawn about attachment to God. Centrality measures the importance of religious beliefs, private and public prayer, religious experience, etc. The centrality model, however, allows testing the hypothesis that the level of centrality differentiates respondents’ attachment to God. I consider this as a crucial point, which should be solved, before the study is to be published in the journal.
Did the Authors control the effect of the disorder on psychotherapy outcomes? The effectiveness of psychotherapy in the treatment of personality disorders or mental disorders is different than in the treatment of neurotic, somatoform or depressive disorders. I think, it should be at least mentioned as a limitation of the study.
Line 44-45: wording „positive mental health characteristics (Kennedy et al. 2015) such as reduced levels of depression and anxiety, well-being, hope and optimism, meaning and purpose, and positive coping skills” can suggest that also reduced levels of well-being, hope, etc.
Line 63: Please clarify what the Authors mean by “the religious intervention”.
Line 71-72 “…there is little support for the assumption that religious interventions are superior to secular ones”. This wording is evaluative and may suggest that the Authors expect religiousness to be superior to secular psychotherapy. I suggest that the Authors express it in a more neutral way.
Line 83: “The concept of centrality by Huber (2003, Huber and Huber 2012) refers to the intensity of religiosity in an individual’s personality”. Centrality is a measure of the importance of religiosity in an individual’s personality.
Some information in the text are missing reference, e.g. lines 169-170: “Empirical evidence for this assumption is the high correlation between the CRS and Attachment to God scales”.
Lines 185-187: “It is possible, that differences in respect to therapy outcomes will occur if the groups are differentiated regarding changes in the centrality of the religious construct system throughout psychotherapeutic treatment.” Please provide rationale for why the Authors made an assumption that the centrality of religiosity changes during psychotherapy. Have religious influences been used on patients?
Lines 188-190: “This consideration corresponds with the assumption of the extended model that the perceived attachment relationship to God (as a central aspect of the religious construct system) has a broader influence on an individual’s experience and behavior if the religious construct system is in a central position in the individual’s cognitive architecture”. This study allows us to conclude that high centrality of religiosity (not attachment to God) affects an individual’s experience and behavior. Attachments to God was not examined by the Authors.
If the participants completed the SCL-90-R, why the Authors have not included these results in the text?
Please provide rationale why the Authors thought that more religious patients would get better psychotherapy results.
Line 147: “Fearful attachment” is in the literature referred as “anxious attachment”.
Author Response
Dear Reviewer,
thank you for the detailed considerations of the present article.
Ad 1:
“The most unclear in the reviewed paper is, in my opinion, the way the Authors connect the centrality of religiosity and attachment to God. The Authors assumed that attachment to God plays a key role in patients with high centrality of religiosity (Lines 292–293: “Therefore, it is assumed that for patients with a high centrality of the religious construct system the perceived attachment to God takes a central position within the individual’s personality”). This assumption was not only not examined empirically (centrality is tested throughout the article), but the Authors did not explain anything about why they think high centrality is associated with attachment to God and what type of attachment is associated with centrality. Furthermore, it is unclear whether: (1) high centrality is related to the importance of attachment to God for the individual or (2) high centrality is associated with a particular type of attachment, for example with high secure attachment and low anxious attachment or vice versa? This has not been explained sufficiently in the paper. Measuring centrality with the CRS does not allow conclusions to be drawn about attachment to God. Centrality measures the importance of religious beliefs, private and public prayer, religious experience, etc. The centrality model, however, allows testing the hypothesis that the level of centrality differentiates respondents attachment to God. I consider this as a crucial point, which should be solved, before the study is to be published in the journal.“
Answer 1:
I fully agree that the relationship between the centrality of religiosity and the attachment to God as different constructs are not sufficiently explained in the paper. Neither theoretically, nor examined empirically. Because the present study is part of a complex theoretical and empirical well-done study in the area of attachment to God and therapy outcome, some considerations came up that the two constructs (centrality and attachment to God) are somehow connected. The first consideration refers to the aspect that the religious construct system has different contents. In monotheistic religions the relationship to God is a core aspect of a believers ‘religiosity’. If the centrality of a individual’s religious construct system is high, the question arises whether the believer’s relationship to God as a content of the religious construct system will also be of high importance to the believer. Therefore, it is conceivable that highly religious believers relationship to God functions as an attachment relationship. In consequence God functions as an attachment figure to whom the believer turns in times of need and stress. The idea is that if the believer experiences love, comfort or support in his attachment to God, this could have an impact on the improvement of mental health issues. Nonetheless, the complex relationship between the two constructs needs to be prepared theoretically as well as empirically. Therefore, I decided to remove this part of the article and only mention the idea in the discussion section.
Ad 2:
„Did the Authors control the effect of the disorder on psychotherapy outcomes? The effectiveness of psychotherapy in the treatment of personality disorders or mental disorders is different than in the treatment of neurotic, somatoform or depressive disorders. I think, it should be at least mentioned as a limitation of the study. “
Answer 2:
The effect of disorder on psychotherapy outcome was not controlled in the present study. This is a limitation of the study and is now mentioned in the discussion section. Moreover, the diagnosis groups are now reported more specifically. Only a small percentage of 5.2% had personality and behavioral disorders, 2.3% schizophrenia. The main groups were F 32–38 affective disorders 45.5% and F 40–48 neurotic stress and somatoform disorders.
Ad 3:
„Line 44–45: wording „positive mental health characteristics (Kennedy et al. 2015) such as reduced levels of depression and anxiety, well-being, hope and optimism, meaning and purpose, and positive coping skills” can suggest that also reduced levels of well-being, hope, etc.“
Answer 3:
This has been corrected in the following way: „Significant results and effects were represented between religious factors and positive mental health characteristics (Kennedy et al. 2015) such as reduced levels of depression and anxiety, and higher levels of well-being, hope and optimism, meaning and purpose, and positive coping skills (Koenig 2012; Mohr et al. 2011; Smith et al. 2007; Zenkert et al. 2014).“
Ad 4:
Line 63: Please clarify what the Authors mean by “the religious intervention”.
Answer 4:
This part is specified:
„Koenig and Larson (2001) reported positive results of the effect of religious interventions (e.g. integrating religious beliefs into therapy strategies in form of religion-based challenges of irrational beliefs or prayer) for the treatment of depression.“
Ad 5:
„there is little support for the assumption that religious interventions are superior to secular ones”. This wording is evaluative and may suggest that the Authors expect religiousness to be superior to secular psychotherapy. I suggest that the Authors express it in a more neutral way.“
Answer 5:
I decided to remove this part and to focus on the question which should be answered in the present study.
“There is no doubt that the integration of religiosity in therapeutic treatment proves to be effective. The question that remains is whether religiosity really can be viewed as a strong resource to improve therapy outcomes.”
Ad 6:
Line 83: “The concept of centrality by Huber (2003, Huber and Huber 2012) refers to the intensity of religiosity in an individual’s personality”. Centrality is a measure of the importance of religiosity in an individual’s personality.“
Answer 6:
After discussing this point with Stefan Huber - I think it is possible that both aspects are relevant in the concept of centrality. If the question is „How often do you pray“ or „How often do you experience situations in which you have the feeling that God or something divine wants to communicate to you?“ it not only reflects the aspect of importance but also the aspect of intensity. If someone prays frequently, we would probably say that he has an intense prayer life, because the activation of the religious construct system has a high frequency Therefore, the following correction was made: „The concept of centrality by Huber (2003, Huber and Huber 2012) refers to the importance and intensity of religiosity in an individual’s personality.“
Ad 7:
„Some information in the text are missing reference, e.g. lines 169–170: “Empirical evidence for this assumption is the high correlation between the CRS and Attachment to God scales”.
Answer 7:
As reported under Ad 1 this part has been removed.
Ad 8:
Lines 185–187: “It is possible, that differences in respect to therapy outcomes will occur if the groups are differentiated regarding changes in the centrality of the religious construct system throughout psychotherapeutic treatment.” Please provide rationale for why the Authors made an assumption that the centrality of religiosity changes during psychotherapy. Have religious influences been used on patients?
Answer 8:
In addition to a predominantly behavioral and psychodynamic-oriented therapy, the clinic chosen for the present study works with a Christian-integrative concept. The Christian-integrative concept addresses Christian beliefs, interpretations and religion-based solutions of situations (e.g. prayer). The manner of understanding disease is reflected in the salutogenic as well as pathogenic religious aspects. Therefore, maladaptive religious thoughts and beliefs are challenged. All religion-based offers are on a voluntary basis. On the other hand, patients could bring religious questions and themes into the therapy process at any time.
A new part was integrated into the article, in which the clinic concept is described.
It is argued that, if the centrality of the religious construct system is high, the individual’s religiosity strongly affects the individual’s mental health – in positive as well as in negative aspects. It is expected that in a clinic, which addresses religious contents in their treatment concept and where maladaptive, irrational beliefs are challenged or religion-based interpretations and solutions help relieve patient’s religious struggles, the centrality of the individual’s religiosity could change during psychotherapeutic treatment. It is conceivable that e.g. through the necessity of solving religious struggles, the interest in religious themes could grow during psychotherapeutic treatment or that a sensibilization of positive religious aspects encourages e.g. more frequent prayer. Therefore, it is expected that centrality of religiosity could change during the psychotherapeutic treatment.
These considerations are now described in the article under point 3.
Ad 9:
Lines 188–190: “This consideration corresponds with the assumption of the extended model that the perceived attachment relationship to God (as a central aspect of the religious construct system) has a broader influence on an individual’s experience and behavior if the religious construct system is in a central position in the individual’s cognitive architecture”. This study allows us to conclude that high centrality of religiosity (not attachment to God) affects an individual’s experience and behavior. Attachments to God was not examined by the Authors.
Answer 9:
As discussed in Ad 1 this part has been removed.
Ad 10:
„If the participants completed the SCL-90-R, why the Authors have not included these results in the text?“
Answer 10:
The focus of the present study was on the question of whether the centrality of religiosity as a categorical variable shows an effect on the improvement of mental health. Therefore, the decision was made to use Jacobson and Truax (1991) classification for the evaluation of the relevance of the improvement of one’s mental health. Thus, only the different groups of the classification for the improvement of mental health were reported in the present study.
Ad 11:
„Please provide rationale why the Authors thought that more religious patients would get better psychotherapy results. “
Answer 11:
“If the centrality of the religious construct system is high, religiosity plays an important role in an individual’s life. Due to the high centrality, those religious issues are highly present in an individual’s life and are not taken lightly. For negative religious content, like feeling guilty or a lack of finding meaning in life, fears of what happens after death, it is assumed that the influence on mental health is strong when the centrality of the religious construct system is high. Furthermore, positive experiences e.g. of orientation and God’s intervention and the feeling of being accepted by God have a greater influence on mental health if the centrality of an individual’s religious construct system is high. This assumption finds some support in the results of studies considering intrinsically motivated religiosity and mental health (Davis et al. 2003; Koenig et al. 2012; Payman and Ryburn 2010; Smith et al. 2003). Huber and Huber (2012) point out that the highly religious individual and the intrinsic religious orientation have some aspects in common.
These considerations are now described in the article in point 3.
Ad 12:
Line 147: “Fearful attachment” is in the literature referred as “anxious attachment”.
Answer 12:
This is correct. In the lines before it is adequately reported, therefore it was a simple overview.
Round 2
Reviewer 2 Report
Dear Author(s),
I appreciate the Authors for making all the corrections and consider their current version as fully acceptable and beneficial outcome for the readers of the journal.
I wish you good luck
