Psychology
2013. Vol.4, No.4, 427-432
Published Online April 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.44060
Combination of Spirituality and Cognitive-Behavioral Family
Therapy on Treatment of Generalized Anxiety Disorders
Mohammad Khodayarifard1, Sayyed Mohsen Fatemi2*
1Faculty of Psychology and Education, U niversity of Tehran, Tehran, Iran
2Department of Psych o logy, Harvard Universi t y , Cambridge, USA
Received June 2nd, 2012; revised Febr ua ry 6th, 2013; accepted March 7th, 2013
Copyright © 2013 Mohammad Khodayarifard, Sayyed Mohsen Fatemi. This is an open access article distributed
under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work is properly cited.
Therapeutic interventions based on specific religious and spiritual teachings have proven to be effective in
dealing with psychological disorders especially general anxiety disorders. Notwithstanding the signs of
effectiveness within the integral approaches consisting of religious, spiritual and family therapy’s inter-
ventions, there are few studies that indicate the exploration of the integrative implications of the afore-
mentioned interventions. Objective: The present research was to examine the effectiveness of integrative
therapeutic interventions consisting of spirituality and Cognitive Behavioral Family Therapy on treatment
of generalized anxiety disorders. Method: Case study. Participants: Two clients (one male aged 43 and
one female, 37 years old). Procedure: Data was obtained based on the clinical interview, DSM-IV-TR
criteria, psychological tests and psychiatrist’s diagnosis. In the course of 55 weekly therapeutic sessions
for the male client and 39 weekly sessions for the female client, a series of techniques with a focus on
cognitive restructuring were applied. The participants were also given coaching skills, relaxation skills,
problem solving techniques, relationship management skills, and positive psychology techniques. The
techniques were: a focus on the integrative implications of spiritual therapy and its emphasis on shared
love for all human beings, love for others regardless of their ethnicity, belief in monotheism and belief in
the day of judgment and hereafter. Findings: The results of pre-tests and post-tests along with a one year
follow-up indicated the efficiency of the treatment while highlighting the vital role of integrative inter-
ventions based on spirituality and family cognitive behaviour therapy. The results also supported the role
of families in contributing to the treatment of the anxiety disorder. Discussion for Further Research:
The enhancement of family members social competencies based on a focus on spirituality and cognitive
behavior techniques may facilitate the process of modification of thinking patterns of clients.
Keywords: Spirituality; Anxiety Disorders; Family Therapy; Cognitive-Behavioral Approach
Introduction
There are research findings that confirm the application and
implications of both spiritual and religious therapy for treating
the general anxiety disorders.
In a case study involving an 18-year-old boy, Walters &
Whitehead (1999) indicated the treatment of anxiety disorder
by spiritual therapy. Researchers on psychological issues have
applied numerous methods based on their school of thoughts,
their research paradigms and their epistemological perspective.
A behaviourist, for example, would classify anxiety as an
unwanted conditioned response, perhaps paired with originally
neutral stimulus. The social situations that may induce the an-
xiety can, therefore, be proscribed. The situations can be linked
to the inducing responses and therefore an avoidance response
may be examined in the context of the situational analysis.
Treatment from this perspective then would focus on de-linking
this specific response from the stimulus. Likewise, a psycho-
analyst would view generalized anxiety as a symptom of a
deeper conflict, for instance, low self-esteem. The treatment
then would focus on improving the client’s view of herself (Al-
bucher, 2005).
Diagnostic Criteria for Generalized Anxiety Disorder
According to Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition Text Revision (DSM-IV-TR, 2000)
generalized anxiety disorder is characterized by:
1) Excessive anxiety and worry (apprehensive expectation),
occurring more days than not for at least 6 months, about a
number of events or activities (such as work or school perfor-
mance).
2) The person finds it difficult to control the worry.
3) The anxiety and worry are associated with three (or more)
of the following six symptoms (with at least some symptoms
present for more days than not for the past 6 months).
Note: Only one item is requi red in children.
a) Restlessness or feeling keyed up or on edge.
b) Being easily fatigued.
c) Difficulty concentrating or mind going blank.
d) Irritability.
*Corresponding author.

M. KHODAYARIFARD, S. M. FATEMI
e) Muscle tension.
f) Sleep disturbance (difficulty falling or staying asleep, or
restless unsatisfying sleep).
4) The focus of the anxiety and worry is not confined to fea-
tures of an Axis I disorder, e.g., the anxiety or worry is not
about having a Panic Attack (as in Panic Disorder), “being em-
barrassed in public (as in Social Phobia), being contaminated
(as in Obsessive-Compulsive Disorder), being away from home
or close relatives (as in Separation Anxiety Disorder), gaining
weight (as in Anorexia Nervosa), having multiple physical
complaints (as in Somatization Disorder), or having a serious
illness (as in Hypochondriasis), and the anxiety and worry do
not occur exclusively during Posttraumatic Stress Disorder.
5) The anxiety, worry, or physical symptoms cause clinically
significant distress or impairment in social, occupational, or
other important areas of functioning.
6) The disturbance is not due to the direct physiological ef-
fects of a substance (e.g., a drug abuse, a medication) or a gen-
eral medical! Condition (e.g., hyperthyroidism) and does not
occur exclusively during a Mood Disorder, a Psychotic Disor-
der, or a Pervasive Developmental Disorder.
The intensity, duration, or frequency of the anxiety and
worry is far out of proportion to the actual likelihood or impact
of the feared event. The person finds it difficult to keep worri-
some thoughts from interfering with attention to tasks at hand
and has difficulty stopping the worry. Adults with Generalized
Anxiety Disorder often worry about every day, routine life cir-
cumstances such as possible job responsibilities, finances, the
health of family members, misfortune to their children, or mi-
nor matters (such as household chores, car repairs, or being late
for appointments). Children with Generalized Anxiety Disor-
der tend to worry excessively about their competence or the
quality of their performance. During the course of the disorder,
the focus of worry may shift from one concern to another.
There is considerable cultural variation in the expression of
anxiety (e.g., in some cultures, anxiety is expressed predomi-
nantly through somatic symptoms, in others through cognitive
symptoms). It is important to consider the cultural context
when evaluating whether worries about certain situations are
excessive.
In children and adolescents with Generalized Anxiety Disor-
der, the anxieties and worries often concern the quality of their
performance or competence at school or in sporting events,
even when their performance is not being evaluated by others.
There may be excessive concerns about punctuality. They may
also worry about catastrophic events such as earthquakes or
nuclear war. Children with the disorder may be overly con-
forming, perfectionist, and unsure of themselves and tend to
redo tasks because of excessive dissatisfaction with less than
perfect performance. They are typically Overzealous in seeking
approval and require excessive reassurance about their perfor-
mance and their other worries (American Psychiatric Asso-
ciation, 2000).
Cognitive-Be havioral Family Therapy
In cognitive-behavioral therapies, various strategies are used
to alter attitudes and perceptions among clients diagnosed with
anxiety. All the theories are based on the assumption that cor-
recting non-adaptive cognition leads to modification of anxi-
ety-avoidance behaviors. Some researchers believe that training
the clients in positive self-talk, modelling, mental review, pro-
blem solving, self-monitoring and social reinforcements reduce
anxiety. The method is especially effective in treatment of an-
xiety (Kanfer, Karoly, & Newman, 1975).
Cognitive-behavioral therapy includes several methods the
common features of which emphasize the impact of cognitive-
behavioral processes in shaping and continuing psychological
disorders. In this therapeutic approach, empirical methods bas-
ed on behaviorism and cognitive therapy are employed to con-
trol and treat improper responsive patterns. In addition, in cog-
nitive-behavioral therapy the emphasis is on intervention, via
reducing the frequency and intensity of maladaptive responses
of the patients to teach new cognitive-behavioral skills to bring
about a significant reduction in undesirable conducts and an
increase in more adaptive behaviors (Zarb, 1992).
Yongsma and Dattilio (2000) distinguished the following
long-term objectives for a cognitive behavioral family therapy
and their techniques were used in this research:
1) Employment of cognitive and behavioral methods to re-
duce anxiety;
2) Gradual confrontation of anxiety creating stimuli;
3) Elimination of intrapersonal, or emotional problems which
have contributed to the app earance of the symptoms of anxiety;
4) Informing and educating the family members about the
symptoms, roots and treatment of anxiety;
5) Preparing the family members to help each other in re-
ducing anxiety;
6) Informing and educating the family members about em-
ployment of specific techniques to reduce anxiety and avoid-
ance behaviors of the person who suffer from anxiety.
In family therapy, many cognitive and behavioral strategies
employed.
Spiritual and Ethical Therapy
Byramkarasu (1999) believes spiritual and ethical therapy is
a style of psychotherapy which necessitates taking apart the two
concepts of “soul” and “spirit” to get into transpersonal (be-
yond individual) concepts.
Soul moves in the direction of uncovering the secrets of in-
timacy and belonging in our daily life, but spirit seeks to find
divinity in our secular activities. On this basis, spiritual therapy
has been presented based on two important principles: Human
being’s arriving at soulfulness, which requires him/her to love
others, love working and love all of his belongings; and human
being’s arriving at spirituality, which requires him/her to be-
lieve in religion, to have faith in the unity of God and belief in
Transformation. Byramkarasu (1999) says that the requirements
for spiritual therapy are:
Love towards Others
This necessitates one to distinguish him/her from other peo-
ple. In this way the lover and the loved are taken apart, and the
individual goes to devotion and self-sacrifice. Then he/she goes
to forgiveness. Forgiving releases one from anger, hate, humi-
liation, and shamefulness. It presupposes that human beings can
think of others perfect or flawless.
Love of Working
When a person loves his job, his work or whatever activity
he has, he would do it devotedly and when doing so, he would
428

M. KHODAYARIFARD, S. M. FATEMI
be directed toward his liveliness and happiness. According to
this, God is present not only in one’s worshiping but also in
every part of one’s daily activities. So an individual who has
faith in God, can progress higher and higher to reach the high-
est position of exaltedness.
A Sense of Belonging
Belonging to the society is to cooperate with others and par-
ticipate in people’s activities. This is the cause of good-will,
sincerity and spirituality. This requires an individual to free
himself/herself from selfishness, self-interest and egotism.
Belief in Holiness and Spirituality
To believe in spirituality means to respect the sanctity of
everything around us. In this way, ordinary objects are experi-
enced as unusual beings. We need to reject all material things
of life to reach spirituality. Choosing to live in private is to
coordinate the body and soul which eventually leads to belong
to Exaltedness.
Belief in the Unity
The belief in divinity means to feel that one is not distinctive
from the outside world (natural and supernatural are together).
This brings human being’s peace and quiet of life. Belief in
unity is the belief of responsibility towards everyone, to feel a
multilateral commitment and to feel an equal policy to establish
friendly relations with the world around us and get mutually
impressed by the integrity of soul, body and mind, which all
produce kindness, compassion and purity.
Belief in Resurrection and Life after Death
This belief highlights the spiritual revitalization and the es-
tablishment of a spiritual bond and union. Death, in this way,
would be the preceding phase before the commencement of a
new phase.
In spiritual therapy, however, the therapist will be able to
help the patient to experience his/her real self and, at the same
time continue his/her clinical treatment, on the basis of the
above-mentioned 6 principles (Willam, 2000).
The present study was designed to examine the effect of
combination of spirituality and cognitive-behavioral family the-
rapy on treatment of generalized anxiety disorders.
Method
Participants
This study examined two participants diagnosed with anxiety
disorders. The diagnosis was made based on the clinical inter-
view, DSM-IV-TR criteria, psychological tests and psychiatric
diagnosis. The diagnosis was made based on the clinical inter-
view, DSM-IV-TR criteria, psychological tests and psychiatric
diagnosis.
Participant 1
Male, aged 43, with a Master degree in Economic, married,
his wife was 40 years old, Master degree in Economic as well,
they have two children a seven year boy and a four year girl).
Treatment Period: 55 sessions.
Participant 2
Female, aged 37, with a PhD degree, Physiotherapist, mar-
ried, her husband was 39 years old, Businessman BA; they
have a three year daught er .
Treatment Period: 39 sessions.
Instruments
In order to identify the disorders, the MMPI and SCL-90-R
tests and the Beck Depression Inventory were administered to
the participants, together with a clinical interview for both. The
interviews were unstructured. Table 1 displays Scores on Beck
Inventory, before, after and follow-up treatment.
Based on MMPI and SCL-90-R results (Diagrams 1 and 2),
the first client was diagnosed with anxiety, depression, and
physical complaints. The participants scored 29 on the long
version and 12 on the short version of the Beck Depression In-
ventory. He was referred to a psychiatrist as well, who con-
firmed the existence of generalized anxiety and depression.
Diagram 1 indicates the pre-treatment, post-treatment & fol-
low-up results of MMPI for the first client. Diagram 2 displays
the pre-treatment, post-treatment and follow up results of SCL-
90-R Test for the first client.
As for the second client, the results of MMPI and SCL-90-R
(Diagrams 3 and 4) showed dissatisfaction with physical con-
ditions, anxiety and depression. The client scored 33 on the
long version and 15 on the short version of the Beck Depres-
sion Inventory, which was indicative of severe depression.
Moreover, the clinical interview and the psychiatric diagnosis
confirmed the existence of generalized anxiety as the major dis-
order in her. Diagram 2 indicates the pre-treatment, post treat-
ment & follow-up results of MMPI for the second client. Dia-
gram 4 displays the re-treatment, post-treatment and follow-up
results of SCL-90-R Test for the second client.
Therapeutically Procedures and Results
Right at the beginning of the session, the client and their
family members were informed of the results of the conducted
tests. They were also notified that the sessions would both take
place in a one to one basis or with the presence of the family
members
In the initial session of the first client, he said that he was
anxious since early childhood and he used to sleep next to her
mother because of that. According to the client’s report both his
mother and his brother were on medication because of anxiety
and depression. He described his marital relationship as re-
stricted and poor. He thought that his wife was generally kind,
but short-tempered and angry. The client also explained that he
himself was a very irritable person. He emphasized the tensions
in his muscles.
The second client complained of recurrent headaches. She
said: “I have serious and lasting headaches and I feel anxious
Table 1.
Scores on Beck Inventory, before, after and follow-up treatment.
Long version Short version
Before treatment 29 (first), 33 (second) 12 (first), 15 (second)
After treatment 7 (first), 9 (second) 1 (first), 2 (second)
Follow-up 6 (first), 1 0 ( second) 2 (first), 3 (second)

M. KHODAYARIFARD, S. M. FATEMI
430
Diagram 1.
The pre-treatment, post-treatment & follow-up results of MMPI (first client).
Diagram 2.
Pre-treatment, p os t -treatment and follow- u p results of SCL-90-R test (first client).
Diagram 3.
The pre-treatment, post- treatment & follow up results of MMPI (second client).
and depressed at all times. My headaches increase in conditions
of stress. Sometimes as a result of short breath and dizziness, I
cannot do anything and cannot sleep either. I usually feel fa-
tigued and I worry too much about my child’s safety.”
The therapist applied therapeutic techniques after evaluation
and diagnosis of client’s problems through clinical interview,
testing and consulting with the psychiatrist. After the results
confirmed the diagnosis of general anxiety disorders for both
clients, the therapist applied cognitive-behavioral techniques such
as self-monitoring, positive thinking, cognitive reconstruction

M. KHODAYARIFARD, S. M. FATEMI
Diagram 4.
Pre-treatment, po st -treatment and follow-u p results of SCL-90- R t es t (sec ond client).
imaginative desensitization and relaxation. The family mem-
bers of the clients were also exposed to a series of programs in-
cluding problem solving skills, communication skills with a
focus on conflict resolution within the family Also, therapist
taught to family members about anxiety and some skills such as
problem solving and discussion about family conflicts. Fur-
thermore, the therapist discussed and implemented integrative
implications of spiritual therapy with an emphasis on shared
love for all human beings, love for others regardless of their
ethnicity, belief in monotheism and belief in the Day of Judg-
ment and hereafter.
In the following sessions, the therapist concentrated on his
method to help the clients to solve the problem through estab-
lishing a healthy, friendly and positive climate.
In regards to the client’s improvement, the psychologist be-
ing the therapist here used the tests MMPI, SCL-90-R and the
Beck Depression Inventory again and announced the results to
the client. As Diagrams 1-4 showed the mental profiles of the
clients are normal and without any symptoms of physical ail-
ment, anxiety, d ep ression, distress.
The sessions were associated with a good understanding of
reflexive and proactive thinking and their different implications.
The clients learned that the reflexive thoughts were mainly in-
dicative of inner insecurity, negativity, doubt and counter pro-
ductive suggestions whereas the proactive thoughts brought
hopefulness, resourcefulness and positive thinking. The clients
received coaching techniques to choose proactive thoughts in-
stead of reflexive thoughts. Each session, the clients were given
exercises to work on the enhancement of proactive thoughts for
the following session. The exercises encouraged them to prac-
tice proactive thinking in between the sessions and examine the
implications on their feeling s and behaviors. In addition, the
clients were exposed to a series of religious and spiritual inter-
ventions where the focus of conversations was on the relation-
ship between meaning and God, values and spirituality, respon-
sibility and spirit. The clients were asked to reflect on religious
sayings such as God is closer to you than the vein of your neck.
They were also invited to deeply think about the impact of
God’s compassion in their own life to the effect that the great-
est sin would be the despair since despair would mean to turn
your back on God. Clients were then encouraged to explore the
implications of spirituality and religious instructions in their
own phenomenological life namely their own lived experiences.
The psychologist subsequently asked for a gathering of all
the members of the families. They got together and reviewed all
the phases of therapeutically sessions. While they made sure of
the health of the clients, they expressed their gratitude and
thanked the therapist. The post-treatment MMPI and SCL-90-R
results were normal for both clients. One year later, in the fol-
low-up phase, none of the clients showed any signs of recur-
rence of the disorder.
Discussion
The present research was designed to investigate the effi-
ciency of combination of spirituality and cognitive-behavioral
family therapy on treatment of Generalized Anxiety Disorders.
The family education program used conflict resolution, relaxa-
tion, individual and family positive thinking, and desensitiza-
tion as its techniques. In addition, the therapist helped the pro-
motion of family relationships and modification of the client’s
thinking pattern through family therapy and by encouraging co-
operation among the family members. The techniques were all
inspired by a focus on the integrative implications of spiritual
therapy with an emphasis on shared love for all human beings,
love for others regardless of their ethnicity, belief in monothe-
ism and belief in the Day of Judgment and hereafter.
Child breeding techniques, socialization techniques of family
members, family disciplinary conducts, class counterparts, so-
ciety, school and the mass media are among the factors which
affect the emergence and persistence of anxiety disorders (Cul-
linan, 2002). Treatments which are based on the cognitive-be-
havioral approach are highly efficient in curing anxiety disor-
ders, particularly generalized anxiety disorder. Gradual desensi-
tization, problem-solving methods, and cognitive reconstruction
are among the techniques which helped the modification of an-
xiety and avoidance behaviors in the clients (see Barret, Dadds,
& Rappee 1996).
In this research, the pre- and post-treatment symptoms were
assessed through clinical interview, psychological tests and the
psychiatrist’s opinion. In the family sessions, the role of family
in the appearance and persistence of mental disorders, and in
establishment of emotional relationships among the members,
together with the nature of family conflicts was emphasised.
Based on these, problem solving and positive thinking tech-
niques were taught to the family members. Moreover, the dis-
order symptoms were controlled through application of self-
regulation and relaxation, the techniques of which were taught

M. KHODAYARIFARD, S. M. FATEMI
too. Comparison of the pre- and post-treatment results of
MMPI and SCL-90-R is indicative of improvement in the vari-
ous indexes of the tests.
As demonstrated by the extra-analytical study by Shadish et
al. (1993), numerous researches confirm the efficiency of fam-
ily therapy in treatment of children and adult problems, since it
identifies and modifies the behavior patterns which maintain
the problem, the problematic attitude sy stems, and the structural,
contextual and historical contributing factors. In the present
study, this issue facilitated treatment and contributed to its con-
tinuation.
One of the probable reasons for the therapeutical effects of
cognitive-behavioral techniques to have treated generalized an-
xiety disorder is due to the team work and the cooperation of a
psychologist and family members with their emphasis on the
client’s religious, spiritual and ethical aspects by reinforcing
these features in the clients. The results obtained from the pre-
sent research are consistent with the results of the researches
done by other researchers. Saavedra’s (2002) case study con-
cerning treatment of anxiety disorder in a client, confirmed the
efficiency of the combined cognitive-behavioral and family the-
rapy approach. Leggier et al. (2003) used individual cogni-
tive-behavioral treatment for seven adolescents diagnosed with
generalized anxiety. Also, he confirmed the efficiency of cogni-
tive-behavioral family therapy.
Anxiety as a trait has a familial association. Although early
studies produced inconsistent findings regarding familial pat-
terns for Generalized Anxiety Disorder, more recent twin stud-
ies suggest a genetic contribution to the development of this
disorder. Furthermore, genetic factors influencing risk of Gen-
eralized Anxiety Disorder may be closely related to those for
Major Depressive Disorder (Culinan, 2007).
It can be concluded that if family members employ appropri-
ate methods of resolving family conflicts, increase their emo-
tional relationships, and, when necessary, correct their educa-
tional and breeding patterns, the conflicts and tensions of the
person suffering from the disorder decrease as well. In addition,
spirituality and cognitive techniques may help clients revise and
rectify their thinking patterns. The present research has some
limitations such as lack of control group and non-selective sam-
pling group.
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