A faith belief is often associated with better mental health as people may draw on religious beliefs to help them cope with adversity (Tepper et al, 2001).
It has also been argued that the ability to integrate faith into bona fide therapies may increase outcomes for faith groups who access services (Smith et al, 2007).
A new systematic review and meta-analysis looks to assess the clinical efficacy of faith based interventions in comparison with standard treatments for common mental health disorders, i.e. depression and anxiety (Andersen et al, 2015).
- The literature search was conducted in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The researchers searched a comprehensive number of health, social science and grey literature databases and published the search strategy in an accompanying online supplement.
- Studies in the review were limited to randomised controlled trials in adults (16 or over) with depression or anxiety diagnosed using either a diagnostic criteria (e.g. DSM IV), attainment of a threshold score on a validated psychological measure (e.g. BDI) or via a clinician diagnosis.
- Studies that included faith based interventions in physical health condition populations were excluded.
- Studies were included if they compared a standard (secular) intervention or control condition with a faith-based intervention.
- Faith-based interventions were only included if they were developed from a bona fide psychological therapy.
- Studies had to include outcomes that used a recognised psychological tool or diagnostic tool.
- 16 studies were included in the systematic review and 8 studies were included in the meta-analysis. All the studies included in the meta-analysis were treatments that focused on depression.
- The faith based cognitive behavioural treatments (F-CBT) included in the review were:
- Christian-CBT (n=6)
- Spiritual-CBT (n=2)
- Muslim-CBT (n=5)
- Jewish-CBT (n=1)
- Taoist-CBT (n=1)
- Adaptations included the discussion of religious teachings as supportive evidence to challenge irrational thoughts, to promote positive coping, a helpful belief system, and incorporated activities such as prayer.
- Muslim-CBT was significantly longer in duration than Christian-CBT or Spiritual-CBT.
- Studies included a mixture of delivery methods such as:
- Computer delivery (n=2)
- Face-to-face groups (n=4)
- Face-to-face individual (n=10).
Risk of bias
- The researchers identified multiple sources of bias with high bias in regards to researcher allegiance and randomisation, allocation and the blinding of outcome assessment.
- Studies included in the meta-analysis indicated that: “those receiving F-CBT for depression improved more than those in control groups”.
- In regards to F-CBT in comparison with standard CBT:
- F-CBT outperformed CBT but this was not significant
- Analysis of Christian-CBT showed that it out performed CBT although this was a smaller effect (-0.59 (-0.95 to -0.23) when compared to the control condition.
- Could not be entered in to formal meta-analysis. Three studies reported that F-CBT outperformed control conditions and this was significant.
- Studies that compared F-CBT to CBT showed a reduced effect over the follow up period.
- The authors of the study concluded that, “there is some indication that faith-adapted CBT appears to be effective, and there is some possible suggestion that F-CBT may be superior to standard CBT in the treatment of anxiety and depression.”
- The authors noted that the effect size was moderate but there was also a “high risk of various biases” that need to be considered in regards to the reliability of the reported effect. There was also an indication that in depression studies, publication bias may over-estimate the benefit of F-CBT.
- Researcher allegiance was a significant source of bias within the analysis. There were also 8 studies in which the primary author delivered the intervention.
- In regards to anxiety, there were not enough studies to conduct an analysis but individual studies indicated that F-CBT may out perform CBT. However, due to the small number of studies no firm conclusions could be reached in relation to effect.
- There was a high level of heterogeneity between the studies and there were too few studies to be able to conduct further analysis to identify the main sources.
This review attempted to explore the effectiveness of faith-based psychological therapy and ended up analysing faith based CBT and its performance relative to standard CBT. Therefore the effect of faith on other bona fide treatments is unknown. The review highlighted the paucity of research and the lack of alternative psychological therapy models that have faith adaptions outside of CBT. The review also highlighted that existing studies are of low methodological quality and poor quality and reporting of trial design means that an effect is highly likely to be an over-estimation.
The review emphasised the multiple sources of bias and the conclusion that faith based CBT could be superior to standard treatment should be taken with a pinch of salt. The more significant difficulty in reaching any firm conclusion is that the majority of the studies included in the review were of a small sample size and meant they were often underpowered; this was especially the case when studies compared faith based CBT to standard-CBT as the difference in effect would be expected to be small to moderate.
The most concerning aspect that the review identified was the poor methodology in relation to the blinding of the analysis of results and that studies did not control for research allegiance. This raises questions over how well the standard interventions were delivered in comparison to the faith based CBT, as it is possible therapist preference for faith based CBT may account for some of the effect of treatment. Also the lead author delivered the intervention in 8 of the included studies, which raises questions of whether the reported effects are replicable and how relevant the findings are for clinical practice.
Currently it seems the state of research literature does not give a clear answer to the added benefit of faith to psychological therapy, and it appears that faith based CBT offers little in addition to standard CBT in terms of clinical effectiveness, as the reported differences diminish at follow up. However, faith based adaption may reduce barriers and improve access to evidence-based therapies in groups of faith.
Anderson N, Heywood-Everett S, Siddiqi N, Wright J, Meredith J, Macmillan D. (2015) Faith-adapted psychological therapies for depression and anxiety: Systematic Review and meta-analysis. Journal of Affective Disorders, 176, 183-196. [PubMed abstract]
Hackett C, Grim BJ. (2006) The Global Religious Landscape: A Report on the Size and Distribution of the World’s Major Religious Groups as of 2010. The Pew Forum on Religion and Public Life: Washington.
Leykin Y, DeRubeis RJ. (2009) Allegiance in psychotherapy outcome research: separating association from bias. Clin Psychol Sci Pr 2009;16:54–65. doi:10.1111/j.1468-2850.2009.01143.x [Abstract]
Smith TB, Bartz J, Richards PS. (2007) Outcomes of religious and spiritual adaptions to psychotherapy: a meta-analytic review. Psychotherapy Research, 17, 643-655. [Abstract]
Tepper L, Rogers SA, Coleman EM, Maloney HN. (2001) The prevalence of religious coping among persons with persistent mental illnesses. Psychiatric Services, 52, 660-665. [PubMed abstract]