https://doi.org/10.52456/WACJO313
Abstract
The rising incidence of mental ill-health, and burgeoning demand on the NHS in the UK, catalysed the development of a faith-based, group CBT intervention by a large Christian church in the northwest of England. Fifty participants (over two phases) were recruited and engaged with practical teaching and supportive small group discussion, heard personal stories from those with lived experience of mental ill-health and completed self-directed homework. The pre to post scores on all outcome measures indicated a steady decrease in distress, anxiety, depression and suicidal ideation. This was sustained at three months follow-up. Retention rates were striking at 94% for phase 1 considering a mid-intervention pivot to an online platform and 84% for phase 2. Considering the intervention’s innovative nature – including faith elements such as singing and prayer alongside CBT principles to support individuals experiencing psychological distress– the mean scores for their relevance and usefulness provide encouraging feedback.
Key words: Online faith-based CBT; COVID-19; church; psychological distress; group intervention
Introduction
In the UK mental health-related illnesses have become the leading cause of disability, and associated socioeconomic costs rose to £119 billion in 2018–19 (NHS England, 2021; O’Shea and Bell, 2020). Prior to COVID-19, one in four UK adults were estimated to experience mental health issues in their lifespan, with an additional two million adults projected to suffer by 2030 (Mental Health Foundation, 2013). Post-pandemic, these estimates may be optimistic at best, with the UK Government data indicating that self-reported mental health worsened during the initial national lockdown of March 2020, and again during a second wave of the virus between October 2020 and January 2021 (HM Government, 2021). These indicative findings may in part reflect what has been referred to as the ‘triple global public mental health challenge’ imposed by COVID-19, which now requires health infrastructures to: (1) prevent negative impacts on mental wellbeing and rising prevalence of mental disorders associated with the pandemic; (2) protect those with pre-existing mental disorders from COVID-19 and its consequences and (3) provide additional public mental health interventions for health professionals and carers (Campion et al, 2020, p. 657). Whilst the post-pandemic outlook and long-term impacts remain uncertain, what is predicted is that this ‘triple’ challenge may prove pervasive and protracted.
Improving Access to Psychological Therapies (IAPT) has become the most popular route to access mental health support in the UK. Approximately 560,000 people are supported by the programme each year, accessing a range of face-to-face and online therapy and programmes to meet individual needs (NICE, 2018). However, due to increasing demand, there are now over 1.69 million referrals to IAPT annually (NHS Digital, 2020) resulting in unfavourable waiting times for patients, significant delays in accessing an initial appointment with a health professional (Baker, 2020) and even instances of practitioner disengagement (Westwood et al, 2017). Whilst community-based mental health services remain an integral part of NHS policy, with plans for the addition of new mental health provisions in the future (NHS England, 2021), it is clear that the NHS and IAPT programme cannot be expected to meet the mental health needs of the nation alone. Consequently, there is a pressing imperative to explore alternative, professionally underpinned community-based interventions that not only help to meet demand for support, but can speak to the wider aspects of health and engage ‘body, mind and spirit’ to help individuals and communities in making the most of their each and every day (Campion et al, 2020; Department of Health and Social Care, 2014; Olesen et al, 2013).
The Christian Church is uniquely placed in modern UK society to support individuals and groups at the heart of local communities, covering a vast geographic area. It is also acknowledged nationally for its breadth, depth and diversity of activity, including the provision of socioemotional support. Local Christian churches have been acknowledged for both their institutional legacy in engaging with issues of societal health and wellbeing and continued ability to evidentially generate a ‘form of personalised, holistic support that is both distinctive and profoundly valuable to national life’ (Noyes and Blond, 2013, p. 2). During the COVID-19 response, one initiative alone brought 1,100 churches and Christian charity partners together to respond to local community needs (including emotional support) during the 2020 lockdowns (Your Neighbour, 2021). Resultantly, Members of the UK Parliament have recognised that ‘No other institution has [the Church’s] national breadth, its local depth or the diversity of its activity’ (Theos, 2020, p. 3), leaving the Christian Church well-placed to play an increasingly vital role in modern mental health challenges of the twenty-first-century society.
Despite recent commitments to diversity and the development of a range of inclusive mental health programmes, efforts to meet the needs of faith communities and accommodate religious aspects in therapeutic programmes remains deficient. Furthermore, the lack of religious dialogue and integrated faith approaches in mainstream, secular therapies may contribute to a reluctance amongst individuals with a religious affiliation from accessing support for their mental health (Adewoye, 2016). Combined, these aspects support a case for the increased inclusion of religious and spiritual aspects in bespoke, voluntary mental health and wellbeing interventions that can meet the diverse, multicultural needs of modern-day Britain (Adewoye, 2016).
Some interventions that have already begun to adopt this approach include religious Cognitive Behavioural Therapy (CBT-r), and faith-based Cognitive Behavioural Therapy (F-CBT) (Anderson et al, 2015; Koenig, 2009; Koenig et al, 2015; Pearce et al, 2015). These unique approaches integrate both ‘Religion’ (R) and ‘Spirituality’ (S) into the course delivery. These key elements (R/S), which describe ‘a set of beliefs and behaviours shared by a community’ (R) and a ‘relationship with a God or higher being’ (S) respectively, are therefore what set faith-based interventions apart from other secular (or atheistic) mental health interventions and wellbeing activities (Anderson et al, 2015, p. 185; Stanley et al, 2011, p. 334).
In recent years there has been a growing receptiveness to the inclusion of R/S in therapies, with one study reporting that 83% of participants who had engaged in previous CBT trials for anxiety and depression indicated positive attitudes towards the inclusion of R/S in therapy (Stanley et al, 2011). In addition, a growing body of research now highlights the benefits of faith-based approaches, which have been shown to improve intervention acceptability, increase treatment receptivity amongst religious groups to be at least as effective as similar, secular counterparts (Adewoye, 2016; Anderson et al, 2015; Ramos et al, 2014; Smith et al, 2007). Existing research also demonstrates that they have the potential to: reduce individual stress levels; decrease suicide rates; decrease substance abuse involvement and positively impact common mental health challenges such as depression and anxiety (Koenig, 2009, p. 284; Razali et al, 1998). Consequently, there is significant support for faith-based therapies, with associated interventions being increasingly seen to ‘represent resources for health and well-being’ that not only demonstrate acceptability, feasibility and efficacy (Anderson et al, 2015), but may also help to break down accessibility and/or attendance barriers, due to the range of familiar, non-clinical community faith-based buildings and contexts in which such therapies can be delivered. With the added potential to simultaneously foster improved connections for individuals within the local community and increase the availability of social support networks that share common beliefs and values, it can be argued that faith-based approaches can play a critical role in meeting the needs of existing religious groups.
This highlights a role for the Christian Church as community stakeholder with the potential to support wider mental health outcomes as part of the UK’s COVID-19 recovery, and to help address unmet need, delivering alternative mental health and wellbeing interventions that reach local people with culturally adapted, faith-based content. The challenge, however, is that historically the efficacy of these approaches has been underexplored (Gutsche, 1994) and, although a recent meta-analysis examining the potential of faith-adapted CBT interventions found them to consistently achieve improved outcomes for individuals, the effect could not be generalised due to methodological differences (Anderson et al, 2015). Additionally, the meta-analysis did not find any studies that had been conducted in the UK, leading the authors to conclude that ‘in order for primary research in this area to inform UK clinical practice, rigorously performed British trials are urgently required’ (Anderson et al, 2015, p. 195).
This paper seeks to answer that call and contribute to an increased evidence base for faith-based CBT-informed group interventions for individuals experiencing mild and moderate psychological distress including depression and anxiety. Considering the current mismatch between services available as part of the IAPT system, the huge and unmet need of individuals struggling with mental health difficulties, and the potential benefits of R/S in treatment for individuals interested in combining CBT with faith aspects, it is a timely endeavour.
In line with modern conceptions of health, this paper does not consider the term ‘mental health’ to be the exclusive opposite of mental ill-health, or necessarily imply the absence of a diagnosed mental health condition (Department of Health, 2014; Dodge et al, 2012). Instead, the term mental health is viewed as a dynamic state in which individuals continually and repeatedly apply the psychological, social and physical skills or resources available to them to manage, reappraise and/or off-set the psychological, social and physical challenges that beset them (Dodge et al, 2012). Accordingly, subjective experiences of ‘wellbeing’ are assumed to be equally dynamic, arising from one’s individual perception of their ability to balance such needs and resources at any given time (with or without support), for the purpose of managing daily living and achieving future aspirations, (Emerson, 1985; Felce and Perry, 1995). Therefore, modern conceptions of mental health require modern, innovative and inclusive interventions – not only to alleviate existing distress, but also as a preventative measure for withstanding mental challenges that could inhibit holistic health and ‘fullness’ of life.
Specifically, the current study explores the acceptability, feasibility and potential effectiveness of a faith-based wellbeing intervention piloted by a flourishing Christian church in the UK during 2020. The course applied faith-based, CBT-informed content to support individuals experiencing psychological distress. The intervention is unique in that it commenced in-person ahead of the first national UK lockdown, before pivoting and completing in an online format during the first wave of COVID-19. Consequently, this study also represents (to the best of the authors’ knowledge) one of the earliest examples of online, faith-based community mental health support offered in the UK during the pandemic.
Aims
The current study aimed to investigate whether a group intervention based on the principles of CBT that includes a Christian faith element is feasible and acceptable to an adult population of faith or no faith. The feasibility and acceptability of the programme will be determined by answering the following questions:
● Is it possible to recruit participants to engage in the programme?
● Is it possible to retain more than 70% of the recruited participants for the entire programme?
● Is it possible to deliver the programme using an online platform?
● Is a faith element in the programme acceptable to participants?
Furthermore, an effect size estimation will be calculated, and a clinically significant analysis will be performed to help inform future studies.
Methods
All participants invited to take part in the study were offered details about the project through a participant information sheet and were invited to consent to taking part by signing a consent form. The development of the course included consulting with the church’s solicitors and insurance company who agreed to underwrite any risks. Rigorous risk management processes were devised including a Risk Flow Chart (available in the appendix) giving practical steps to implement in the event of any emerging risks to self or others. The writing of the course material was a collaborative effort in consultation with multidisciplinary healthcare professionals (e.g. GP, psychologists, registered mental health nurse) and people with lived experience of mental health difficulties.
The course sought to give people the tools, the support and the environment to strengthen their mental health and consisted of three key features:
Techniques and concepts from Cognitive Behavioural Therapy (CBT);
Personal stories from people with lived experience of mental health difficulties that have improved their wellbeing;
Practical elements of the Christian tradition i.e., singing, Bible verses and prayer.
Phase 1
The course was initially designed to be delivered face to face over six consecutive sessions with each week building upon the previous one. The topics covered during the first phase included: (1) starting out: building momentum (behavioural activation), (2) managing anxiety and stress better, (3) taking care of your body, (4) thinking about your thinking, (5) acknowledging, allowing and processing your feelings and (6) building community. At the start of the course, each participant was offered a book containing information about the material covered during the course (available on request from the authors). Participants were encouraged to use the books weekly to support them during the sessions as well as record any relevant information about their wellbeing as they attended the sessions each week.
Phase 2
The second phase followed the same principles but was adapted so it could be delivered on the online platform. Additionally, following participants’ feedback the course was expanded and delivered over eight weeks. The new format of the course consisted of: Week one: Starting out: Building momentum, Week two: Managing stress better (part one), Week three: Managing stress better (part two), Week four: Taking care of your body, Week five: Managing your feelings (part one), Week six: Managing your feeling (part two), Week seven: Managing your thoughts, Week 8: Putting it all together: building community.
Study design
The current study took the form of a case-series design. Case-series design is an essential research method that can be used to evaluate an intervention at an early stage and form the foundations for empirically sound knowledge (Iwakabe and Gazzola, 2009). A case-series study typically involves a small number of participants (Abu-zidan et al, 2012). As a result, close examination of complex patterns and relationships between various factors can be explored. Considering attrition rates of around 30% for group interventions (based on CBT principles) (Fanous and Daniels, 2020), the study aimed to collect data from at least 15–20 participants during each phase.
Participants
Participants were invited to take part in the study using a brief verbal advert in a church in Manchester as well as through the church’s social media accounts. Individuals interested in strengthening their mental health were invited to enquire further about the format of the course and sign up if interested.
Inclusion criteria
In order to take part in the study and access the course, participants were required to be aged eighteen and over, be currently experiencing mental health difficulties, be interested in strengthening/improving their mental health, and be able to read and understand English.
Exclusion criteria
Any participants with severe learning difficulties or mental health challenges that were severely impacting their everyday functioning were not included in the study. In addition to this, any individuals under the care of the NHS services such as Home-Based Treatment Team (Crisis Team) or Community Mental Health Team (where individuals are offered short-term community support as an alternative to inpatient care), actively suicidal, substance abuse dependants or those that at the time of the course were accessing other forms of support such as therapy or counselling were not included in the course.
Measures
The Clinical Outcomes in Routine Evaluation-Outcome Measure 10 (CORE-10) (Barkham et al, 2013) was used weekly to assess session-by-session change throughout the six-week (Phase 1)/eight-week (Phase 2) course due to its short and practical nature. The questionnaire contained ten statements that could be scored on a scale from 0 (not at all) to 4 (most or all the time). Alpha (internal reliability) for CORE-10 is 0.90 (Barkham et al, 2013).
The Generalised Anxiety Disorder-7 (GAD-7) (Spitzer et al, 2006) was used pre-, halfway and post course . The GAD-7 measure is efficient in assessing and identifying generalised anxiety disorder. It is a short and practical measure used in routine practice as well research. The measure contains seven items that can be scored from 0 (not at all) to 3 (nearly every day). Scores of 8 or greater are indicative of caseness. Scores between 0–5 indicate mild levels of anxiety, 6–10 moderate, 11–15 moderately severe and 16–21 severe. The measure is reliable and valid with an overall internal reliability of 0.92 (Spitzer et al, 2006).
The Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al, 2001) was used pre-, halfway and post course. The PHQ-9 was used to assess depression in participants. It uses the same scoring system as GAD-7 with items scored from 0 (not at all), 1 (several days), 2 (more than half the days) to 3 (nearly every day). The total scores are interpreted in the following manner: 5 – mild, 10 – moderate, 15– moderately severe, 20 – severe. The measure has great internal reliability with a Cronbach’s overall score of 0.89. Scores 10 or above are indicative of caseness.
Additionally, all participants were invited to fill in a weekly session evaluation form, which asked them to rate the extent to which each segment (singing, teaching, discussion, prayer and homework) of the session was relevant and helpful on a scale of 0 (not at all) to 10 (entirely). This helped reveal to what extent the proposed intervention as delivered in this format was acceptable to participants.
If, during the course, any of the participants disclosed safeguarding or risk concerns either verbally or through their responses on the outcome measures, a trained facilitator spoke to the participant immediately and used the Risk Flow Chart to assess risk and take any necessary action.
Intervention
Phase 1
Individuals interested in the course were invited to fill in an expression of interest form. Participants were then contacted and met with two group facilitators. Participants were also offered an information sheet containing all information necessary to help participants make an informed decision about taking part in the study. Participants were required to sign a consent form confirming their desire to voluntarily take part. Participants were given up to a week to consider the information and return the signed consent forms.
Following this, participants were invited to attend the course on church premises (pre-COVID-19). All individuals came together in the same room and were assigned a seat at a particular table during the course of the evening. Participants were divided in small groups of 3–5 participants with 2–3 facilitators assigned to support each group. The project recruited a total of twelve course facilitators. These consisted of professionals working with or having experience of supporting individuals experiencing mental health difficulties. The facilitators were not required to deliver or teach any materials during the course. Their role was to facilitate discussions following the teaching sessions, which were delivered by the course leader. The facilitators were instructed to use the questions provided in the supporting booklets (that were handed out to each participant) to generate discussions and foster conversations among participants. Individuals were encouraged to sit with the same group throughout the time of the course. The sessions lasted approximately two hours and followed the same format each week. During the first part of the session individuals were invited to engage in an optional time of singing to begin the evening. Participants were reminded that they did not have to take part unless they chose to. Following this, the course leader would spend time talking to the entire group for 30–35 minutes on a chosen topic. The topic was different each week. Following this, participants were directed to engage in conversation with their small group and explore the material that was presented. Participants were encouraged to contribute to the discussion when/if they felt comfortable. As part of each session participants were then encouraged to spend a few minutes in a self-directed homework setting task, which included considering how they might practically apply some of the information heard during the teaching slot. The sessions would typically end in an optional short time of prayer.
Phase 2
The procedure for the second phase followed the same process used when the course was first delivered with a few adaptations, the main one being delivering the course entirely online. Individuals were informed about the course through the church’s online platform. All interested participants were invited to fill in an expression of interest form. The participants were then contacted and invited to attend a short meeting through Zoom (online video chatting platform) where they were offered more details about the course and were given the opportunity to ask any questions. Participants were informed that the course would be delivered online using Zoom. Although online, the format of the course remained the same. Participants were invited to engage in a short time of singing. A video of recorded singing in church was used to facilitate the time of singing in lieu of the in-person experience provided during Phase 1. Participants were encouraged to join in only if they felt comfortable. Participants were reminded that they could turn off their camera and microphones. Following this, the course leader addressed the whole group and presented the course material applicable for each week. Then, using the breakout room feature available on Zoom, participants were invited to join a room where they were part of a small group. In here, participants were encouraged to discuss the material heard (for approximately thirty minutes), set homework (for approximately five minutes) and spend a few minutes in prayer (approximately ten minutes). On completion of this, the small groups would all return to the main room where the course leader would conclude the evening.
Analysis
The computer software Statistical Package for the Social Sciences (SPSS) version 23 was used to present descriptive data, including means and standard deviations for the three outcome measures used during the intervention. The CORE-10 measure was used to understand participants’ levels of distress. A score of 10 and below is representative of non-clinical levels of distress whereas a score of 11 or above indicates clinical levels of distress. Scores lower than 10 are split in two categories: healthy (0–5) and low level (5–10). Scores 11–14 would indicate mild psychological distress, 15–19 moderate psychological distress, 20–24 moderate to severe and 25–40 severe psychological distress. Participants improving by 6 or more points from pre- to post course would be classed as achieving reliable improvement. Any participants who at the beginning of the course scored 11 or above but on completion of the course obtained scores of 10 or below would be considered as achieving clinically significant change. In order to achieve reliable and clinically significant change participants needed to meet both criteria – cross the cut-off value and move six or more points in the direction of recovery. Participants whose scores at the beginning of the course were below the cut-off value were only able to achieve reliable change. Participants were classed as recovered if they achieved both reliable and clinical significant change, improved if they achieved reliable change, no change if neither reliable or clinical change occurred and deteriorated if participants achieved reliable change but in the opposite direction (Connell and Barkham, 2007).
The GAD-7 and PHQ-9 were used to identify levels of anxiety and depression. For GAD-7, scores of 8 or greater while for the PHQ-9 scores of 10 or greater are indicative of caseness. Scores between 0–5 indicate mild levels, 6–10 moderate, 11–15 moderately severe and 16 and over – severe (Kroenke et al, 2010). Reliable change required participants to improve their baseline score by four points for anxiety and by six points for anxiety.
The current project also sought to understand if the course had the potential to be effective in reducing levels of distress, anxiety and depression. Consequently, an estimation of effect size was calculated using the Wilcoxon Signed-Rank Test and the corresponding effect size. Considering the current project only used a small sample and no control group was used, a conservative approach was used to determine estimation of effect size. For the missing data that was not available for all participants at the end of the study and at follow up, the principle of last observation carried forward was used (Unnebrink and Windeler, 2001). The results were interpreted using Cohen’s criteria where .1 is indicative of small effect, .3 indicative of medium effect and .5 indicative of large effect (Cohen, 1988). It is hoped these results will help inform future studies in which a control group might be considered.
Results
Recruitment and retention
Phase 1
A total of eighteen participants (two males and sixteen females) with ages ranging from twenty-one to fifty-three signed up to the intervention. Of these, eleven individuals identified as White British, five as Black British and two as Black African. Two reported being unemployed, three were students, one a volunteer and twelve in paid employment. As the intervention included elements of the Christian faith, participants were asked if they regularly attended church. A total of fourteen participants indicated that they regularly attend church, two indicated that they watch a religious service online and one suggested that they sometimes attend church.
All participants attended the first three sessions face to face. Unfortunately, due to COVID-19 restrictions, the course had to be paused before resuming online after an eight-week break. Additionally, given the impact and pressure of COVID-19 on individuals’ mental health and wellbeing it was considered that resuming the course might contribute to increased wellbeing and offer individuals support/help to navigate unprecedented times. Of the eighteen participants that commenced the course, a total of seventeen participants resumed the course online on Zoom. Participants were invited to attend a ‘welcome back session’ prior to returning to the course material. The ‘welcome back session’ allowed participants the opportunity to familiarise themselves with the online forum and understand how the course would be facilitated on this platform. The team aimed to mirror the same course format that participants were familiar with when the session took place face to face. Each participant was added to a Zoom breakout room following the teaching session so they could conduct their discussion/reflection. Participants were clustered according to the same groups established at the beginning of the course. On completion of the course, seventeen participants were retained from the original eighteen that started the course leading to a retention rate of 94.4%. One participant indicated that the online platform was not suitable, so they stopped attending when lockdown commenced.
Phase 2
For the second phase, the intervention consisted of eight sessions delivered fully online. A total of thirty-two individuals commenced the course: five males and twenty-seven females. Participants’ age ranged from twenty-one to sixty-four years old. For full details of participants’ demographics please see Table 1. During the first three weeks, five participants decide to stop attending the course. The reasons for this varied: a couple of individuals found it difficult to access the material using the online platform while one participant experienced a bereavement and expressed their desire to access the course at a later time. Two participants did not provide details regarding their decision to stop attending the sessions. One participant presented with complex difficulties and found it difficult to engage with the group format. Another participant dropped out and was uncontactable. A total of twenty-seven participants completed the eight-week course demonstrating a retention rate of 84.3%. At the three months follow-up assessment a total of seventeen participants filled in the outcome measures.
Suitability of the intervention
Participants provided detailed feedback regarding their perceptions of the intervention as a whole in the form of an interview. The findings for these have been reported elsewhere (Churchman et al, 2022 in press). In addition to this, all participants rated each section of the course (singing, teaching, discussion, prayer and homework) in relation to its relevance and helpfulness on a scale of 0 (not at all) to 10 (entirely). The forms were completed for each session. A summary of the means and standard deviations scores from the participants are presented in Table 2a for Phase 1 and Table 2b for Phase 2. Participants were also encouraged to add comments on the form that would help the course facilitators understand how they might improve the course. The majority of the mean scores reported were 8 or above. There were a few exceptions where participants’ scores were lower. Some comments from the participants included technical difficulties, which made it difficult to engage, or the sessions feeling rushed and not leaving enough time for discussion, homework or prayer.
Outcomes
Phase 1
During the first phase of the intervention, a total of twelve (of eighteen) participants were experiencing levels of distress that exceeded the normal/expected levels and were classed as experiencing clinical levels of distress. Participants’ distress ranged from severe to mild. Detailed information about the number of participants falling into each category can be found in Table 3a.
Participants were also asked to fill in the GAD-7 and PHQ-9 questionnaires. All but one participant reported some level of anxiety or depression in their lives prior to accessing the intervention. The levels of anxiety varied from mild for four participants, moderate for four participants, moderately severe for six participants and severe for four participants. A total of five participants displayed mild levels of depression, five reported moderate levels, three moderate-severe levels and four were recorded as experiencing severe depression. On investigating further, it was established that ten (out of eighteen) participants met the criteria for anxiety diagnosis while nine (out of eighteen) participants met the criteria for depression diagnosis. A total of eight participants met the criteria for both anxiety and depression diagnosis.
Furthermore, six participants disclosed that in two weeks prior to beginning the course they had been bothered by thoughts that they would be better off dead or of hurting themselves in some way. Five participants reported on the CORE-10 that they had made plans to end their lives in the week leading up to them starting the course.
On completion of Phase 1, a total of nine (out of ten) participants showed improvements in their wellbeing. The improvement varied for each individual. Detailed information on participants’ progress can be found in Table 3a. Of the ten participants (who completed the course and met the criteria for clinical levels of distress), six participants achieved reliable change. Furthermore, two were classed as fully recovered and no longer experiencing clinical levels of distress, while two made no change.
On the anxiety scale, a total of four participants showed a real movement in symptoms large enough to be classed as recovered. A further two achieved reliable change in their improvement and three made no change. The remaining eight (of the total seventeen who completed the study) presented with sub-clinical scores.
Participants also made progress on their level of depression. Three participants fully recovered and one improved. Four participants achieved no change. The remaining nine did not meet the threshold for clinical levels set out at the beginning of the study.
More importantly, on completion of the study no participants reported any self-harm or suicidal thoughts. Another area that participants reported improvements in relation to was their mood. At the beginning of the course, a high number of participants (N=13) reported feeling down, depressed or hopeless. Some (N=3) disclosed feeling like this nearly every day while the majority (N=9) reported it happened several days a week. Following completion of the course, the majority of participants (N=8) stated that they no longer felt hopeless or depressed. The remaining participants reported feeling this less often.
Table 4a provides a summary of means and SD for all three outcome measures used throughout the course. The pre- to post scores on all outcome measures show a steady decrease, therefore, indicating decrease in distress, anxiety and depression. This is sustained at the three months follow-up assessment. The estimation of effectiveness demonstrated large effect size on the CORE-10 measure (r=55) and GAD-7 measure (r=54) and medium to large on PHQ-9 (r=38). This was sustained at follow-up assessment with a slight increase for the depression measure (r=48).
Phase 2
During Phase 2, of the thirty-two participants that commenced the course, a total of twenty-three met the criteria for clinical levels of distress with the majority of participants presenting with moderate or moderate-severe levels of psychological distress. More details are available in Table 3b. On the anxiety scale, participants reported severe (N=8), moderate-severe (N=8), moderate (N=7) and mild (N=8) levels of anxiety prior to engaging in the course. A total of seventeen individuals met the criteria for generalised anxiety disorder. On the depression scale, fifteen individuals met the criteria for caseness.
At the end of the course, a total of twenty participants filled in the CORE-10 measure. Of these, only eight reported clinical levels of distress. The results showed that on completion of the course six participants recovered, four improved and five achieved no change.
For the other two outcome measures (GAD-7 and PHQ-9) a total of eighteen participants filled in the forms. In this group, six did not meet the caseness threshold for anxiety and ten for depression at the beginning of the study. On the anxiety scale, a total of seven individuals were recorded as recovered, two improved and three as achieving no change. On the depression scale, three recovered, two improved and three achieved no change. Table 4b provides a summary of means and SD for all three outcome measures used throughout the course. The CORE-10 mean scores display a steady decrease from pre- to post course. The effects size estimations mirror the findings detailed during Phase 1 with large effects on the distress and anxiety measure and medium to large for the depression measure. Results were sustained three months after completion of the study.
Discussion
The prevalence of mental health challenges, limited public resources and now the added ‘triple global public mental health challenge’ imposed by COVID-19 make it clear that the NHS and IAPT programme cannot be expected to meet the mental health needs of the UK alone. The Christian Church is uniquely placed in modern society to support individuals and groups experiencing mental health challenges. Sitting at the heart of local communities across the UK, the Church is already acknowledged for its institutional legacy in engaging with issues of societal health and wellbeing, and for providing significant social support within and beyond Christian faith communities.
Given the growing receptiveness to the inclusion of R/S in therapies, this study sought to help bridge the gap in academic literature concerning the feasibility, acceptability and efficacy of faith-informed interventions in the UK. Overall, the suitability of the intervention, its format and content yielded positive findings, resulting in: positive recruitment and retention rates; strong acceptability and significant efficacy for the majority of participants.
Recruitment and retention
Recruiting and retaining participants as part of a psychological intervention has often been a challenge for researchers and practitioners (Coatsworth et al, 2015). Studies have shown that drop-out rates for group CBT intervention can vary from 15% to 50% (Friedlander, 2014) with more recent findings recording a rate of 30% (Fanous and Daniels, 2020). Inevitably, drop-out rates negatively impact recovery rates for individuals, as those who start but disengage from treatment have less opportunities to achieve change and recover. In light of this, the current findings where 94% (during Phase 1) and 84% (during Phase 2) of participants were retained for the whole intervention are significant.
The increased need for cost-effective and efficient programmes has made way for the considerations of group interventions as part of the IAPT service. As a result, it has been proposed that group CBT has the potential to be more cost-effective than individual CBT while equality efficacious (Fanous and Daniels, 2020). The current overall retention rate (88%) reported across both phases adds to the current literature suggesting faith-based interventions have the capacity to improve acceptability and increase treatment retention (Adewoye, 2016; Anderson et al, 2015; Ramos et al, 2014).
Furthermore, retaining individuals to complete a full course of treatment is a well-known issue in the IAPT service. Reports show that of the total referrals ending in 2019–20, only 36.8% of individuals finished treatment. The remaining 63.2% of referrals (that ended in 2019–20) did not complete a course of IAPT treatment (NHS Digital, 2020). In the current intervention, a total of 94% (during Phase 1) and 84% (during Phase 2) of individuals commencing the course completed the respective six or eight weeks. Therefore, it is essential to continue to explore the potential for faith-based interventions and their ability to offer interventions that meet the needs of individuals and thus leading to low attrition rates.
Acceptability
Participants submitted self-reported scores for each section of each session, which demonstrated that the intervention, its components as well as the environment in which this was delivered, were acceptable to the participants. Compared to other faith-based or group interventions, the current initiative sought detailed feedback regarding each component of the intervention and used participants’ feedback to improve and continue developing the intervention. Considering the innovative nature of the current intervention that included faith elements (in the form of singing and prayer) alongside CBT principles to support individuals experiencing psychological distress, the mean scores for their relevance and usefulness provide encouraging feedback. The mean score obtained for singing was 9.27 while for prayer it was 9.03. These findings demonstrate positive attitudes towards including faith elements in psychological interventions which are in line with previous research. Stanley et al (2011) reported that 83% of participants that engaged in previous CBT trials for anxiety and depression indicated positive attitudes towards the inclusion of R/S in therapy (Stanley et al., 2011). In comparison, more traditional aspects of CBT interventions such as homework received a score of 8.63. Some participants found the task overwhelming or did not engage with it despite this being self-directed.
While considering the usefulness and relevance of each session overall, records show that all sessions apart from session 5 obtained of score higher than 9. Week 5, which focused on acknowledging, allowing and processing feelings, scored a mean of 8.46. Participants’ additional comments revealed that a couple of participants experienced technical difficulties that prevented them from engaging in the discussion and homework part of this session.
During Phase 2, when the intervention was delivered entirely online, session 1, 2 and 5 received a mean score lower than 9. For session 1, lower scores revealed some participants felt anxious or worried about interacting and opening up using the internet platform as well as running out of time to engage in prayer at the end of the session. For session 2 and 5, participants reported running out of time to discuss their difficulties or missing the singing section at the beginning and therefore offering lower ratings.
In contrast to the intervention delivered during Phase 1 (which took place part in person, part online), the singing and prayer sections received a mean score of 8.98 and 8.91. Additional feedback revealed that some participants missed the singing section at the beginning by logging in late or due to technical difficulties and thus offered very low scores (1 out of 10) and ran out of time to engage in prayer at the end. Considering this was an early attempt to offer a group psychological intervention using an online platform during a global pandemic and lockdown, the current study paved the way and demonstrated the potential for support to be offered online both during but more importantly post COVID-19.
Overall, the suitability of the intervention, its format and content yielded positive findings thus building on the positive recruitment and retention rates. When compared with other studies offering similar group interventions consisting of four, six or seven weeks (Young-Southward et al, 2020), the detailed feedback showed that individuals found the intervention relevant and helpful. Young- Southward et al explored client satisfaction for group CBT interventions for mild and moderate anxiety from a total of 103 individuals that attended an initial session. They reported that only 53.4% of individuals completed the full course of treatment. This raised concerns given the short time commitment required to complete a full course of treatment.
Outcomes
During Phase 1, of the eighteen participants providing baseline data, a total of twelve experienced clinical levels of distress. At the end of the intervention, of the ten participants (who completed the course and met the criteria for clinical levels of distress) six participants achieved reliable change while two achieved both clinical and reliable change thus being classed as recovered. On the anxiety scale, four participants recovered and two achieved reliable change. Furthermore, on the depression scale, three recovered and one improved. In addition to this, estimated effect sizes for both Phase 1 and Phase 2 (with large effects on distress and anxiety scales and medium-large on the depression scale) demonstrate the intervention’s potential for effectiveness, which should be explored further.
When compared to current IAPT services where recovery rates have been modest with latest findings showing 51% of individuals that have entered and completed treatment have recovered (NHS Digital, 2020), the current intervention warrants further exploration.
Despite the promising findings, these results should be considered with caution. The exploratory nature of the initiative should not be dismissed. Additionally, more studies will be required to establish the clear effectiveness of the intervention. Future studies should evaluate the intervention’s transferability and consider if further adaptations are required. It is also important to highlight that only a small number of participants did not have a connection to the church or a faith background. The majority of the participants attended the church that offered the intervention, thus contributing to potential bias in response to questions regarding improvement and acceptability of faith elements.
Conclusions
While the evidence base for group interventions continues to grow, the current study has provided early findings on the feasibility of faith-based group intervention and its ability to retain participants. The proposed initiative shows great promise as an alternative form of psychological support for individuals experiencing mild to moderate difficulties. There are many advantages associated with an intervention of this kind including: increased accessibility, high retention, low cost, personalised care as well as the importance of introducing R/S as part of the treatment intervention.
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Acknowledgements
The authors are extremely grateful to all the participants who engaged with the course and gave their time to provide feedback on the intervention. Additionally, the authors are extremely grateful for the group facilitators who volunteered their time to support the participants during the intervention. Lastly, the authors would like to thank the senior leaders and the board of trustees of the hosting church who made this project possible.
Disclosure statement
The authors declare no competing interests.
Funding
No funding was received to conduct this study.
About the authors
Anamaria Churchman, PhD, CPsychol
Anamaria Churchman is a lecturer at The University of Manchester where she completed her PhD in Clinical Psychology. Her research interests include the role of transdiagnostic approaches particularly Method of Levels therapy in supporting individuals experiencing psychological distress. Ana is also interested in the role of faith and its links to wellbeing. Email: anachurchman@audaciouschurch.com
Affiliation: Audacious Church, Trinity Way, Manchester, M3 7BD
Lianna Roast, Msc., MBPsS
Lianna Roast spent seventeen years working in the not-for-profit sector before recently completing her Masters in Disaster Management at Bournemouth University. Lianna’s research interests focus on learning from major incidents and disasters, as well as building psychological, community and wider societal resilience. Email: liannaroast@gmail.com
Affiliation: Audacious Church, Trinity Way, Manchester, M3 7BD
Julie Keir, DipTh., CDRS MA
Julie leads Audacious Wellbeing; developing interventions for church and community that are faith based, psychologically informed and evidence based. She is also a BACP Accredited Psychotherapist and Supervisor. She gained her Masters in Counselling and Psychotherapy at London Met University in 2010 and her Diploma in Theology at Mattersey Hall in 1993. Julie is passionate about empowering the Church to have an active role in promoting mental health and alleviating distress. Email: juliekeir@audaciouschurch.com
Affiliation: Audacious Church, Trinity Way, Manchester, M3 7BD
Copyright 2022 Dr Ana Churchman, Lianna Roast & Julie Keir
Table 1: Participant demographics by phase group
Table 2a: Suitability of intervention Phase 1
Table 2b: Suitability of intervention Phase 2
Table 3a: Levels of distress, anxiety and depression pre- and post course – Phase 1
Table 3b: Levels of distress, anxiety and depression pre- and post course – Phase 2
Table 4a: Changes to sample mean (SD) and effect size for Phase 1
Table 4b: Changes to sample mean (SD) and effect size for Phase 2