Research

FAITH BASED INTERVENTION IN DEPRESSION, ANXIETY AND OTHER MENTAL DISTURBANCES

George A. Hurst, MD, FACP, FCCP; Marion G. Williams, BS; Judith E. King, LMSW, ACSW; and *Richard Viken, MD

From the Office of the Director Emeritus and the *Department of Family Practice,
University of Texas Health Center at Tyler

Reprint requests to George A. Hurst, MD, University of Texas Health Center at Tyler 11937 US Highway 271, Tyler, Texas 75708-3154

Supported by Grants from Watson W. Wise Foundation, The Cain Foundation, Robert M. Rogers Foundation, East Texas Communities Foundation, and Willingham Foundation to the Ministry of Healing, and the R.W. Fair Foundation to the University of Texas Health Center at Tyler.

None of the authors have any commercial interest in Freedom in Christ Ministries, Ministry of Healing, or materials mentioned in the manuscript.

The Texas study protocol was approved by the Institutional Review Board of Regent University Virginia Beach, Virginia.

Objective: To determine if the effects of using the Steps to Freedom would be beneficial for a group of individuals who attended a Christian Conference.
Methods: A user-friendly 12-item questionnaire was used to monitor the outcomes of Steps to Freedom addressing six Symptom/Behavioral problems and six Function Areas. In addition, the Symptom Checklist-90 R (SCL-90-R) questionnaire was employed to document the validity of the shorter questionnaire. The questionnaires were completed before and after the administration of the Steps to Freedom. The Wilcoxon Matched Pairs Test was used to measure the significance of the findings for the 12-item questionnaire.
Results: 33 clients who went through the Steps to Freedom showed statistically significant improvement (P<0.005) at 3-4 months in all Symptom/Behavior categories (items 1-6). All Function Areas (items 7-12) also demonstrated statistically significant improvement (P≤0.05). A comparison group who did not attend the conference or receive counseling showed no significant changes during the same period.
Conclusion: These significant preliminary findings need to be confirmed by additional studies. Steps to Freedom model prayers, utilized by individual patients personally and/or with a counselor, could expand the care and hopefully lower the cost of mental illness.

Key Words:

  • Intentional religion − Exposure to religion at a particular time for a particular purpose
  • Steps to Freedom – Faith-based model prayers to help individuals resolve personal and spiritual conflicts
  • Discipleship Counseling − Faith-based therapy utilizing Steps to Freedom format

Key Points:

  • Mental illness is common and costly. Depression and anxiety disorders are the most common mental illnesses.
  • Research on outcomes of intentional religion in mental illness is uncommon.
  • Benefits of Steps to Freedom, a faith-based example of intentional religion, on depression, anxiety and other mental disorders are reported.

In 2002, according to the U.S. Surgeon General, one in five adult Americans experienced a mental health disorder each year. Sadly, less than a third of these adults and even fewer children receive any mental health services.1 Mental disorder frequency is increasing. The National Institute of Mental Health (NIMH) in 2007 reports that an estimated one in four (26.2 per cent) Americans 18 and older suffer from a diagnosis of a mental disorder each year. Mood disorders (depression) and anxiety disorders, the two most common mental illnesses, affect 20.9 million and 40 million American adults annually.2 Anxiety disorders include the following: generalized anxiety, panic disorder, obsessive-compulsive disorder, post traumatic stress disorder and phobias.2 In 1998 the reported total yearly cost for mental illness in both the private and public sectors in the U.S. was $205 billion with $92 billion coming from direct treatment costs and the remaining coming from lost productivity, crime and welfare costs.3
There has been an interest in the study of the relationship between religion and/or spirituality and health for 35 years with research reporting a connection between religion and health.4-7 Most of the studies that have addressed the relationship between religion and health have been what Johnson describes as “organic religion.”8 That is, the influence of religion practiced over time in an array of social and behavioral outcomes. A review of 669 studies of organic religion revealed that a higher religious involvement is associated with: less depression, reduced likelihood of suicide, as well as other health and social benefits.8 The studies also reported increased levels of well-being, meaning in life and other benefits.
In contrast to organic religion, Johnson states that there has been an overlooked dimension of the outcomes of religion in what is referred to as “intentional religion.”8 Intentional religion is the exposure to religion one receives at a particular time in life for a particular purpose. Examples would be faith-based programs to combat delinquency or drug use among teens,9 and to reduce recidivism rates in post release prisoners.10 Johnson found the two year post-release reincarceration rate among InnerChange Freedom Initiative graduates from Texas was 60 percent less compared to a matched comparison group.10 Steps to Freedom in Christ is an example of intentional religion. Steps to Freedom, when utilized by a counselor to facilitate the use of model prayers with a client, has been described as Discipleship Counseling.11
Certain disciplines of religion such as prayer and the act of forgiving and their impact on physical and psychological health have been studied many years.12-14 Lack of studies of intentional religion is particularly noticeable in the area of emotional/mental outcomes. With the cooperation of an interdenominational faith based organization, Freedom in Christ Ministries (FICM), we surveyed outcomes of Steps to Freedom (Discipleship Counseling) in a multi-center study.15

Methods
This study used a new 12 item Likert scale questionnaire designed to test whether a faith-based intervention would have a positive effect in individuals with a variety of emotional/mental and behavioral difficulties. The outcome study was carried out on 33 individuals who attended a Living Free in Christ Conference in Edmond, Oklahoma or in Tyler, Texas. The three and one-half day conferences dealt with issues relating to resolving personal and spiritual conflicts. The conference subject is expounded in the books “Victory Over the Darkness” and “The Bondage Breaker” by Anderson.16,17

Client Selection
Announcements were made in the general session offering conference attendees an opportunity to make an individual appointment with a counselor. All of the individuals desiring to become clients filled out a “Request for Conference Appointment” (Figure 1). The conference staff verified the information and interviewed each group member. The process resulted in the selection of 38 clients in Oklahoma and 40 clients in Texas from the larger groups by the coordinator. The selection was made on the basis of the following priorities: 1) presence of significant depression including suicidal tendencies, anxiety and other typical presenting problems; 2) availability of the client during the three days following the conference. The clients were matched (women with women counselors) with trained lay (un-licensed) counselors.
A comparison “control” group consisted of 40 volunteers who attended the Tyler, Texas host church on the Sunday after the conclusion of the conference. These individuals had not attended the conference and had never gone through the Steps to Freedom.
Study participants were asked to read and sign an Adult Consent Form.

Steps to Freedom Format
Each Step to Freedom appointment utilizes prayers to ask forgiveness and have faith in God to enable clients to address and resolve past and present personal and spiritual problems. Steps to Freedom appointments were offered free of charge and lasted approximately 6 or 7 hours. In Discipleship Counseling literature, the lay counselors are referred to as encouragers and clients are referred to as counselees.11 Steps to Freedom addresses seven areas of beliefs and practices, and the details are outlined in chapter 13 of “The Bondage Breaker”17

Study Design
A 12-item questionnaire was completed before the appointment. At the conclusion of the Steps to Freedom session the client was given a post appointment questionnaire and a self-addressed stamped envelope and asked to return the questionnaire in 7 days. Another post appointment questionnaire with a self-addressed stamped envelope was mailed 3-4 months later to each client. In Texas, each client and comparison (control) member was also given the SCL-90-R questionnaire along with the 12-item questionnaire. The lengthy SCL-90-R questionnaire has been subjected to extensive research, and has demonstrated scientifically acceptable validity and reliability.
The 12-item study questionnaire refined and expanded a 10-item questionnaire developed by coauthor JEK. Items 1-6 deal with problem Symptom/Behavior patterns. Items 7-12 reflect Function status in emotional, relational, physical, and spiritual areas of life. Pilot studies using both the 10 item and 12-item questionnaires were carried out in Michigan.18
A Psy D graduate student from Regent University in Virginia Beach, VA analyzed the Texas data to determine the validity of the 12- item questionnaire compared to the SCL-90-R results in his dissertation.19 The averaged correlations between the first six items of the 12-item questionnaire and selected SCL-90-R measures are: Depression with Depression (0.721, P≤.000), Anxiety with Phobic Anxiety (O.724, P≤.000), Fear with Anxiety (0.740, P≤.000), Anger with Hostility (0.657, P≤.000), Tormenting Thoughts and Voices with Psychoticism (0.723, P≤.000), Habits and Behavior with Obsessive-Compulsive (0.521, P≤.000). Most SCL-90-R items did not match well with items 7-12 (Function status) of the 12-item questionnaire.
The changes in the pre- and post- (3-4 mos.) questionnaire replies to each item were tested for significance using the Wilcoxon Matched Pairs Test20 at the P< 0.05 level. This test is a nonparametric analog to the paired-sample t test and was used because the data provided the magnitude and direction of the changes.

Results
Data from 33 clients at 3-4 months are depicted in Table 1. The post-counseling percent decrease (improvement) in Symptom/Behavior was: ─49% for Depression, ─44% for Anxiety, ─49% for Fear (irrational), ─45% for Anger (unhealthy), ─42% for Tormenting Thoughts and Voices, and ─46% for Habits and Behavior. All the changes were statistically significant for all categories at P ≤0.005. Statistically significant changes P ≤0.05 (improvement) occurred in all of the six Function areas. The greatest percent improvement was in Self-esteem (+45) and Satisfactory Relationships (+42).
The comparison group, which received no counseling (Table 1), showed some changes at 3 months which were not significant. Anxiety, Habits and Behavior scores increased.

Discussion
The study results have demonstrated that clients receiving Steps to Freedom Counseling had significant decreases in all Symptom/Behavior categories at 3-4 months along with improvement in Function areas. The appointment length is designed to assist the client to explore every important area of beliefs and practices and to identify and resolve the hurts in their life. Whether the improved Symptom/Behavior scores resulted in betterment of Function Areas or vice/versa is not known. It is known that an individual’s spiritual, psychological and physical conditions are interrelated and affect self-esteem and various life functions.
Secondary study benefits were: the demonstration of the validity of the short 12-item questionnaire and that trained laypersons can serve as counselors. Most patients suffer from more than one negative Symptom/Behavior problem and the ability to use single questions to identify and quantify these Symptom/Behavior categories could prove useful.
There were study limitations including: possible client selection bias, the absence of a randomized control group, lack of clinical information regarding clients, and decreasing survey response from post 1 week to 3-4 months. Therefore, these preliminary results need further confirmation.
. We cannot with certainty attribute all positive results to what the client accomplished during the counseling session. Some of the Symptoms/Behaviors such as depression could have improved with time, but they also could have become worse. However, based on the Comparison group results, it seems unlikely that all the Symptom/Behavior categories would have improved with time without intervention.
Treatments for Anxiety disorders are benzodiazepines and anti-depression medications, especially those that increase serotonin (SSRI). Benzodiazepines can be habit forming. Any benefit from Steps to Freedom that would decrease or eliminate the dependency on medication has positive potential.
A majority of patients with depression have their initial medical contact with primary care physicians (PCPs) who have little or no time to provide counseling.21 Counseling has been shown to provide additional benefit to a SSRI medication in a study of chronic major depression.22 In addition to considering psychotherapy, the PCPs should refer patients with thoughts of suicide and/or harm to others to a psychiatrist.
A spiritual history of about four questions is recommended to be a part of a patient’s work up.23,24 One may need to ask only one or two questions to determine a patient’s beliefs and/or religious background as part of obtaining the initial personal/social history.25 A proposed ethic for physicians obtaining information about patient’s spiritual/religious matters has been addressed.13,25,26 If the spiritual history reveals an appropriate candidate for Christian faith-based intervention, the physician could recommend the following: suggest the patient obtain and read the book which contains the Steps to Freedom and follow the suggested prayers.17Additional information regarding the availability of Discipleship Counseling services can be provided by the FICM in Knoxville, TN.25

Conclusion
This outcome survey of the impact of Steps to Freedom on emotional/mental disorders reveals significant decrease in all problem Symptom/Behavior categories. There was also an associated improvement in Function areas. These benefits, we believe, are related to the client’s participation in the Steps to Freedom appointment. Further studies are needed to confirm these preliminary data. Steps to Freedom can be recommended in addition to medications and psychotherapy in mental/behavior disturbances and could reduce the cost of mental illness.

Acknowledgements
The authors are grateful to Hal Parks for coordinating the Steps to Freedom appointments, the many lay counselors, clients and comparison members for participating in the study, Dr. Fernando Garzon and Robert Kenneth Crabtree (PsyD candidate) for providing important questionnaire analyses, Tom Craig for supplying reference material, the several funding sources, Marsha Buchheit for administrative help during the study and Donna Patillo for technical support.

References

  1. National Mental Health Association Resource Center. Mental health facts 2002.
  2. National Institute of Mental Health: Numbers Count: Mental Disorders in America. 6001 Executive Boulevard, Bethesda, Maryland 20892.
  3. Rice DP, Miller LS. “Health economics and cost implications of anxiety and other mental disorders in the United States”. Br J Psychiatry 1998; 173:4-9.
  4. Comstock GW, Partridge KB. Church attendance and health. J Chron Dis 1972; 25:665-672.
  5. Levin JS, Larson DB, Puchalski CM. Religion and spirituality in medicine: research and education. JAMA 1997; 278:792-793.
  6. Matthews DA, McCullough ME, Sawyers JP, Milano MG, Larson DB, Koenig HC. Religious commitment and health status. Arch Fam Med 1998; 7:118-124.
  7. Koenig HG. Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J 2004; 97:1194-1151.
  8. Johnson BR. Assessing the effectiveness of faith-based organizations (FBO). Health and Spirituality Connection. 2002; 6:3, 6.
  9. Johnson BR, Jang, SJ, Larson DB, Li SD. Does adolescent religious commitment matter? a re-examination of the effects of religiosity on delinquency. J. Res Crime Delinq. 2001; 38:22-44.
  10. Johnson BR, Larson DB. 2003. The InnerChange Freedom Initiative: Evaluating a Faith-Based Prison Program, CRRUCS Report, Philadelphia: University of Pennsylvania, and New York: Center for Civic Innovation, The Manhattan Institute.
  11. Anderson NT. Discipleship Counseling. 2003 Regal Books. A division of Gospel Light. Ventura, California 93006.
  12. Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J 1988; 81:286-288.
  13. Matthews DA, Marlowe SM, MacNutt FS. Effects of intercessory prayer on patients with rheumatoid arthritis. South Med J 2000; 93: 1177-1186.
  14. Worthington EL Jr. Dimensions of Forgiveness: Psychological Research and Theological Perspectives. 1999 Philadelphia Templeton Foundation Press.
  15. Anderson NT, President Emeritus, Parks H, Chairman of the Board, Freedom in Christ Ministries, 9051 Executive Park Dr., Knoxville, TN 37923
  16. Anderson NT. Victory Over the Darkness. 2000 (second edition) Regal Books from Gospel Light. Ventura, California 93006.
  17. Anderson NT. The Bondage Breaker. 2000 Harvest House Publishers, Eugene, Oregon 97402.
  18. Anderson NT, Garzon F, King JE. Released from Bondage. 2002:150-151 Thomas Nelson Publishers, Nashville, Tennessee.
  19. Robert Kenneth Crabtree. PsyD Graduate Thesis. The Library Regent University. Virginia Beach, Virginia 23463.
  20. Wilcoxon F. Individual comparisons by ranking methods. Biometrica Bull 1945; 1:80-83.
  21. Williams JW, Rost K, Dietrich AJ, Ciotti MC, et al. Primary care physicians’ approach to depressive disorders. Arch Fam Med 1999, 8: 58-67.
  22. Keller MD, McCullough JP, Klein DN, Arnow B, Dunner DL, Glennberg AJ, et al. A comparison of nefazodone, the cognitive behavioral analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 2000; 342: 1462-1470.
  23. Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patient more fully. J Palliat Med 2000; 3:129-137.
  24. Mangans TA. The spiritual history. Arch Fam Med 1996; 5:11-16
  25. Smalligan RD. Combining spirituality and medicine: one physician’s approach. South Med J 2005; 98:1240-1241.
  26. Curlin FA, Hall DE. Strangers or friends? A proposal for a new spirituality-in-medicine ethic. J Gen Intern Med 2005; 20:370-374.

Table 1. Counseled and Comparison Group Results (post 3-4 months, 3 months)

Counseled Group N=33 Comparison Group N=18
Symptom/Behavior* Pre Post % Change** Pre Post % Change**
1. Depression (hopelessness) 4.79 2.45 -49*** 2.28 2.11 -07
2. Anxiety 5.12 2.85 -44*** 2.28 2.78 +22
3. Fear (irrational) 4.39 2.24 -49*** 1.61 1.61 00
4. Anger (unhealthy) 4.55 2.52 -45*** 2.17 2.22 +03
5. Tormenting Thoughts 4.53 2.64 -42*** 1.44 1.22 -15
and Voices
6. Habits and Behavior over 4.59 2.48 -46*** 2.00 2.41 +21
which you have little control
*1 is no problem, 10 is severe; ** – Signifies improvement; ***Changes were significant at P

Counseled Group N=33 Comparison Group N=18
Function in Following Areas* Pre Post % Change** Pre Post % Change**
7. Self-esteem 5.50 7.97 +45*** 8.11 8.67 +07
8. Ability to Function in 7.30 8.30 +14*** 9.00 9.33 +04
daily activities
9. Satisfactory Relationships 5.59 7.91 +42*** 8.28 8.56 +03
10. Physical Health 5.70 7.70 +35*** 7.72 7.83 +01
11. Bible Study and Prayer 6.48 7.85 +21*** 7.72 8.17 +06
12. Reality of God in your life 7.05 8.73 +24*** 9.22 9.28 +01
*1 is not well, 10 is very well; ** + Signifies improvement; ***These changes were significant at P

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