Exploring the Feasibility of Behavioural Activation Therapy Delivered by Faith Leaders for Depression in Pakistan

Background: Statutory healthcare services are overstretched, impeding access to mental healthcare in Pakistan. Many people with mental disorders, including depression, turn to faith leaders for support. Simple but effective psychotherapeutic treatments for depression can be delivered by trained lay workers, potentially including faith leaders.

Research Questions: My research questions were: 1) Is it feasible for faith leaders to deliver behavioural activation for depression in Pakistan? and 2) What adaptations need to be made to behavioural activation so faith leaders can deliver it in Pakistan?

Methods: I used a mixed methods approach and conducted four interrelated studies: 1. A systematic review to understand pathways to accessing mental healthcare in Pakistan; 2. A systematic review on the effectiveness of interventions by faith leaders for common mental disorders, including barriers and facilitators to their delivery; 3. Qualitative interviews with faith leaders; and 4. with individuals with depression attending them.

Findings: The first systematic review (12 studies) found that one-third of people with mental illness first contact faith leaders in Pakistan. The second review (33 studies) highlighted that "spiritual passe" interventions are effective for common mental disorders. In spiritual passe, faith leaders move their hands over an individual without touching to heal illness. In qualitative study with faith leaders (N = 12), they expressed interest in receiving training to manage depression with subtle resistance to becoming trainees of healthcare professionals. The qualitative study involving people with depression who attended faith leaders (N = 13) highlighted the beneficial effects of faith leaders' interventions while showing dissatisfaction with faith leaders' understanding of mental illnesses.

Conclusion: There are two barriers to behavioural activation delivered by faith leaders, including the limited autonomy of attendees in their interactions with faith leaders and power tension between faith leaders and healthcare professionals. There is a need for dialogue between faith leaders, healthcare professionals, and attendees on integrating faith-based practices in behavioural activation without compromising the autonomy of attendees and core elements of behavioural activation.